hospital_name,last_updated_on,version,hospital_location,hospital_address,license_number|FL,"To the best of its knowledge and belief, the hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date indicated.",,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
Northwest Florida Community Hospital,7/1/2024,2.0.0,Northwest Florida Community Hospital,"1360 Brickyard Road Chipley, FL 32428",596002711,TRUE,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,
description,code|1,code|1|type,code|2,code|2|type,code|3,code|3|type,setting,drug_unit_of_measurement,drug_type_of_measurement,standard_charge|gross,standard_charge|discounted_cash,modifiers,standard_charge|Aetna|Commercial|negotiated_dollar,standard_charge|Aetna|Commercial|negotiated_percentage,standard_charge|Aetna|Commercial|negotiated_algorithm,estimated_amount|Aetna|Commercial,standard_charge|Aetna|Commercial|methodology,additional_payer_notes|Aetna|Commercial,standard_charge|BLUE_CROSS_NWB|Commercial|negotiated_dollar,standard_charge|BLUE_CROSS_NWB|Commercial|negotiated_percentage,standard_charge|BLUE_CROSS_NWB|Commercial|negotiated_algorithm,estimated_amount|BLUE_CROSS_NWB|Commercial,standard_charge|BLUE_CROSS_NWB|Commercial|methodology,additional_payer_notes|BLUE_CROSS_NWB|Commercial,standard_charge|BLUE_CROSS_PHS_PPO|Commercial|negotiated_dollar,standard_charge|BLUE_CROSS_PHS_PPO|Commercial|negotiated_percentage,standard_charge|BLUE_CROSS_PHS_PPO|Commercial|negotiated_algorithm,estimated_amount|BLUE_CROSS_PHS_PPO|Commercial,standard_charge|BLUE_CROSS_PHS_PPO|Commercial|methodology,additional_payer_notes|BLUE_CROSS_PHS_PPO|Commercial,standard_charge|CIGNA|Commercial|negotiated_dollar,standard_charge|CIGNA|Commercial|negotiated_percentage,standard_charge|CIGNA|Commercial|negotiated_algorithm,estimated_amount|CIGNA|Commercial,standard_charge|CIGNA|Commercial|methodology,additional_payer_notes|CIGNA|Commercial,standard_charge|FLORIDA_COMMUNITY_CARE|MEDICAID|negotiated_dollar,standard_charge|FLORIDA_COMMUNITY_CARE|MEDICAID|negotiated_percentage,standard_charge|FLORIDA_COMMUNITY_CARE|MEDICAID|negotiated_algorithm,estimated_amount|FLORIDA_COMMUNITY_CARE|MEDICAID,standard_charge|FLORIDA_COMMUNITY_CARE|MEDICAID|methodology,additional_payer_notes|FLORIDA_COMMUNITY_CARE|MEDICAID,standard_charge|HUMANA|Commercial|negotiated_dollar,standard_charge|HUMANA|Commercial|negotiated_percentage,standard_charge|HUMANA|Commercial|negotiated_algorithm,estimated_amount|HUMANA|Commercial,standard_charge|HUMANA|Commercial|methodology,additional_payer_notes|HUMANA|Commercial,standard_charge|HUMANA|MEDICAID|negotiated_dollar,standard_charge|HUMANA|MEDICAID|negotiated_percentage,standard_charge|HUMANA|MEDICAID|negotiated_algorithm,estimated_amount|HUMANA|MEDICAID,standard_charge|HUMANA|MEDICAID|methodology,additional_payer_notes|HUMANA|MEDICAID,standard_charge|HUMANA|MEDICARE|negotiated_dollar,standard_charge|HUMANA|MEDICARE|negotiated_percentage,standard_charge|HUMANA|MEDICARE|negotiated_algorithm,estimated_amount|HUMANA|MEDICARE,standard_charge|HUMANA|MEDICARE|methodology,additional_payer_notes|HUMANA|MEDICARE,standard_charge|LIGHTHOUSE|MEDICAID|negotiated_dollar,standard_charge|LIGHTHOUSE|MEDICAID|negotiated_percentage,standard_charge|LIGHTHOUSE|MEDICAID|negotiated_algorithm,estimated_amount|LIGHTHOUSE|MEDICAID,standard_charge|LIGHTHOUSE|MEDICAID|methodology,additional_payer_notes|LIGHTHOUSE|MEDICAID,standard_charge|MEDICAID|negotiated_dollar,standard_charge|MEDICAID|negotiated_percentage,standard_charge|MEDICAID|negotiated_algorithm,estimated_amount|MEDICAID|,standard_charge|MEDICAID|methodology,additional_payer_notes|MEDICAID|,standard_charge|MEDICARE|negotiated_dollar,standard_charge|MEDICARE|negotiated_percentage,standard_charge|MEDICARE|negotiated_algorithm,estimated_amount|MEDICARE|,standard_charge|MEDICARE|methodology,additional_payer_notes|MEDICARE|,standard_charge|SUNSHINE|MEDICAID|negotiated_dollar,standard_charge|SUNSHINE|MEDICAID|negotiated_percentage,standard_charge|SUNSHINE|MEDICAID|negotiated_algorithm,estimated_amount|SUNSHINE|MEDICAID,standard_charge|SUNSHINE|MEDICAID|methodology,additional_payer_notes|SUNSHINE|MEDICAID,standard_charge|UHC|COMMERCIAL|negotiated_dollar,standard_charge|UHC|COMMERCIAL|negotiated_percentage,standard_charge|UHC|COMMERCIAL|negotiated_algorithm,estimated_amount|UHC|COMMERCIAL,standard_charge|UHC|COMMERCIAL|methodology,additional_payer_notes|UHC|COMMERCIAL,standard_charge|WELLCARE|MEDICAID|negotiated_dollar,standard_charge|WELLCARE|MEDICAID|negotiated_percentage,standard_charge|WELLCARE|MEDICAID|negotiated_algorithm,estimated_amount|WELLCARE|MEDICAID,standard_charge|WELLCARE|MEDICAID|methodology,additional_payer_notes|WELLCARE|MEDICAID,standard_charge|min,standard_charge|max,additional_generic_notes
OFIRMEV(ACETAMINOPHEN)1000MG INJ:100ML,25,CDM,250,RC,,,Outpatient,,,144,144,,,,,,Other,Not Separately Reimbursable,118.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,118.8,82.5,,95.04,percent of total billed charges,Pays at 82.5% of total Billed charges,105.12,73,,84.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.8,70,,80.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.63,19.19,,22.104,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72,50,,57.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.63,118.8,
LEAD WIRES 3 SET 24 ECG FOR 2ND,1257,CDM,270,RC,,,Outpatient,,,71.25,71.25,,,,,,Other,Not Separately Reimbursable,58.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.78,82.5,,47.024,percent of total billed charges,Pays at 82.5% of total Billed charges,52.01,73,,41.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.88,70,,39.904,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.67,19.19,,10.936,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.63,50,,28.504,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.67,58.78,
SPO2 CABLE FOR MIDRAY,1258,CDM,270,RC,,,Outpatient,,,78.75,78.75,,,,,,Other,Not Separately Reimbursable,64.97,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.97,82.5,,51.976,percent of total billed charges,Pays at 82.5% of total Billed charges,57.49,73,,45.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.13,70,,44.104,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.11,19.19,,12.088,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.38,50,,31.504,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.11,64.97,
TELEMETRY CABLE FOR MINDRAY WALL,1259,CDM,270,RC,,,Outpatient,,,210,210,,,,,,Other,Not Separately Reimbursable,173.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,173.25,82.5,,138.6,percent of total billed charges,Pays at 82.5% of total Billed charges,153.3,73,,122.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,70,,117.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,19.19,,32.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,50,,84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,173.25,
MASK BIPAP LARGE,2075,CDM,270,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
"HEMOTROL LEVEL 1, 2 VIALS",3853,CDM,270,RC,,,Outpatient,,,36.03,36.03,,,,,,Other,Not Separately Reimbursable,29.72,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,29.72,82.5,,23.776,percent of total billed charges,Pays at 82.5% of total Billed charges,26.3,73,,21.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.22,70,,20.176,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,19.19,,5.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.02,50,,14.416,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,29.72,
"HEMOTROL LEVEL 2, 2 VIALS",3854,CDM,270,RC,,,Outpatient,,,36.03,36.03,,,,,,Other,Not Separately Reimbursable,29.72,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,29.72,82.5,,23.776,percent of total billed charges,Pays at 82.5% of total Billed charges,26.3,73,,21.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.22,70,,20.176,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,19.19,,5.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.02,50,,14.416,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,29.72,
"HEMOTROL LEVEL 3, 2 VIALS",3855,CDM,270,RC,,,Outpatient,,,36.03,36.03,,,,,,Other,Not Separately Reimbursable,29.72,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,29.72,82.5,,23.776,percent of total billed charges,Pays at 82.5% of total Billed charges,26.3,73,,21.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.22,70,,20.176,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,19.19,,5.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.02,50,,14.416,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,29.72,
COUDE CATH 12FR 5CC,3863,CDM,270,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
COUDE CATH 14FR,3864,CDM,270,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
COUDE CATH 18FR 5CC,3866,CDM,270,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ENDOTRACH HOLDER,3940,CDM,270,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
UNNA BOOT 3,4037,CDM,270,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DURAPREP SOLUTION W APPLICATOR 26ML,4602,CDM,270,RC,,,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
DRESSING - AQUACEL EXTRA AG 4X5,7019,CDM,270,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
PACER PADS CHILD (ZOLL),81498,CDM,270,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
PENROSE DRAIN .25 (1/4),85526,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
NS 50 ML,89025,CDM,270,RC,82274,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
FECAL IMMUNOCHEMICAL TEST,182949,CDM,301,RC,36430,HCPCS,Outpatient,,,79,79,,,,,,Other,Not Separately Reimbursable,65.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,65.18,82.5,,52.144,percent of total billed charges,Pays at 82.5% of total Billed charges,57.67,73,,46.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.3,70,,44.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,19.19,,12.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.5,50,,31.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,65.18,
BLOOD TRANSFUSION,236430,CDM,391,RC,96365,HCPCS,Outpatient,,,643,643,,,,,,Other,Not Separately Reimbursable,530.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,530.48,82.5,,424.384,percent of total billed charges,Pays at 82.5% of total Billed charges,469.39,73,,375.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,450.1,70,,360.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,123.39,19.19,,98.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,321.5,50,,257.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,123.39,530.48,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",296365,CDM,761,RC,96372,HCPCS,Outpatient,,,402,402,,,,,,Other,Not Separately Reimbursable,331.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,331.65,82.5,,265.32,percent of total billed charges,Pays at 82.5% of total Billed charges,293.46,73,,234.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,281.4,70,,225.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.14,19.19,,61.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,201,50,,160.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.14,331.65,
"INJECTION, SC/IM",296372,CDM,761,RC,96374,HCPCS,Outpatient,,,143,143,,,,,,Other,Not Separately Reimbursable,117.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,117.98,82.5,,94.384,percent of total billed charges,Pays at 82.5% of total Billed charges,104.39,73,,83.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.1,70,,80.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.44,19.19,,21.952,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.5,50,,57.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.44,117.98,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",296374,CDM,761,RC,99195,HCPCS,Outpatient,,,365,365,,,,,,Other,Not Separately Reimbursable,301.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,301.13,82.5,,240.904,percent of total billed charges,Pays at 82.5% of total Billed charges,266.45,73,,213.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255.5,70,,204.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.04,19.19,,56.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182.5,50,,146,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.04,301.13,
PHLEBOTOMY THER SPX,299195,CDM,761,RC,99211,HCPCS,Outpatient,,,127,127,,,,,,Other,Not Separately Reimbursable,104.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,104.78,82.5,,83.824,percent of total billed charges,Pays at 82.5% of total Billed charges,92.71,73,,74.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.9,70,,71.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.37,19.19,,19.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.5,50,,50.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.37,104.78,
Outpatient visit of established patient not requiring a physician,299211,CDM,761,RC,99212,HCPCS,Outpatient,,,128,128,,,,,,Other,Not Separately Reimbursable,105.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,105.6,82.5,,84.48,percent of total billed charges,Pays at 82.5% of total Billed charges,93.44,73,,74.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.6,70,,71.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,19.19,,19.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64,50,,51.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,105.6,
Outpatient visit of established patient requiring a physician,299212,CDM,761,RC,99213,HCPCS,Outpatient,,,204,204,,,,,,Other,Not Separately Reimbursable,168.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,168.3,82.5,,134.64,percent of total billed charges,Pays at 82.5% of total Billed charges,148.92,73,,119.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,142.8,70,,114.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.15,19.19,,31.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102,50,,81.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.15,168.3,
"Established patient office or other outpatient visit, typically 15 minutes",299213,CDM,761,RC,99214,HCPCS,Outpatient,,,213,213,,,,,,Other,Not Separately Reimbursable,175.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,175.73,82.5,,140.584,percent of total billed charges,Pays at 82.5% of total Billed charges,155.49,73,,124.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.1,70,,119.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.87,19.19,,32.696,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,106.5,50,,85.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.87,175.73,
"Established patient office or other outpatient visit, typically 25 minutes",299214,CDM,761,RC,99215,HCPCS,Outpatient,,,243,243,,,,,,Other,Not Separately Reimbursable,200.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,200.48,82.5,,160.384,percent of total billed charges,Pays at 82.5% of total Billed charges,177.39,73,,141.912,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.1,70,,136.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.63,19.19,,37.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121.5,50,,97.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.63,200.48,
"Established patient office or other outpatient, visit typically 40 minutes",299215,CDM,761,RC,87070,HCPCS,Outpatient,,,313,313,,,,,,Other,Not Separately Reimbursable,258.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,258.23,82.5,,206.584,percent of total billed charges,Pays at 82.5% of total Billed charges,228.49,73,,182.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,219.1,70,,175.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.06,19.19,,48.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,156.5,50,,125.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.06,258.23,
Test of body fluid other than blood to assess for bacteria,919182,CDM,306,RC,87070,HCPCS,Outpatient,,,34.6,34.6,,,,,,Other,Not Separately Reimbursable,38.49,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,38.49,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,25.26,73,,20.208,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.22,70,,19.376,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.64,19.19,,5.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.3,50,,13.84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.64,38.49,
TEST CULTURE ANAEROBIC,919183,CDM,306,RC,87086,HCPCS,Outpatient,,,34.6,34.6,,,,,,Other,Not Separately Reimbursable,28.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.55,82.5,,22.84,percent of total billed charges,Pays at 82.5% of total Billed charges,25.26,73,,20.208,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.22,70,,19.376,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.64,19.19,,5.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.3,50,,13.84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.64,28.55,
TEST CULTURE (URINE),919184,CDM,306,RC,87206,HCPCS,Outpatient,,,7.75,7.75,,,,,,Other,Not Separately Reimbursable,6.39,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6.39,82.5,,5.112,percent of total billed charges,Pays at 82.5% of total Billed charges,5.66,73,,4.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.43,70,,4.344,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.49,19.19,,1.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.88,50,,3.104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.49,6.39,
TEST FUNGUS SMEAR,919185,CDM,306,RC,87206,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
TEST CULTURE/SMEAR FUNGUS,919186,CDM,306,RC,87045,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,24,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,24,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,24.09,
TEST CULTURE (STOOL),919187,CDM,306,RC,87040,HCPCS,Outpatient,,,18.7,18.7,,,,,,Other,Not Separately Reimbursable,15.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,15.43,82.5,,12.344,percent of total billed charges,Pays at 82.5% of total Billed charges,13.65,73,,10.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.09,70,,10.472,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.59,19.19,,2.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.35,50,,7.48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.59,15.43,
TEST CULTURE (BLOOD) BACTERIAL,919189,CDM,306,RC,87070,HCPCS,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,9.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.08,82.5,,7.264,percent of total billed charges,Pays at 82.5% of total Billed charges,8.03,73,,6.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.7,70,,6.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,19.19,,1.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.5,50,,4.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,9.08,
TEST CULTURE (THROAT),919190,CDM,306,RC,87070,HCPCS,Outpatient,,,11.22,11.22,,,,,,Other,Not Separately Reimbursable,9.26,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.26,82.5,,7.408,percent of total billed charges,Pays at 82.5% of total Billed charges,8.19,73,,6.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.85,70,,6.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.15,19.19,,1.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.61,50,,4.488,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.15,9.26,
TEST CULTURE (ENVIROMENTAL),919191,CDM,306,RC,87252,HCPCS,Outpatient,,,218,218,,,,,,Other,Not Separately Reimbursable,179.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,179.85,82.5,,143.88,percent of total billed charges,Pays at 82.5% of total Billed charges,159.14,73,,127.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,152.6,70,,122.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.83,19.19,,33.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109,50,,87.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.83,179.85,
TEST CULTURE (VIRAL),919192,CDM,306,RC,87177,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,73.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,73.43,82.5,,58.744,percent of total billed charges,Pays at 82.5% of total Billed charges,64.97,73,,51.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.3,70,,49.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,19.19,,13.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.5,50,,35.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,73.43,
TEST O&P,919193,CDM,306,RC,87070,HCPCS,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
Test of body fluid other than blood to assess for bacteria,919194,CDM,306,RC,87046,HCPCS,Outpatient,,,29.26,29.26,,,,,,Other,Not Separately Reimbursable,38.49,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,38.49,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,21.36,73,,17.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.48,70,,16.384,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.61,19.19,,4.488,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.63,50,,11.704,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.61,38.49,
TEST CULTURE (STOOL VIBRIO ONLY),919195,CDM,306,RC,87070,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,27.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.23,82.5,,21.784,percent of total billed charges,Pays at 82.5% of total Billed charges,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,27.23,
TEST CULTURE (SPUTUM),919196,CDM,306,RC,87116,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,9.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.9,82.5,,7.92,percent of total billed charges,Pays at 82.5% of total Billed charges,8.76,73,,7.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.4,70,,6.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,19.19,,1.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6,50,,4.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,9.9,
TEST CULTURE ACID FAST,919197,CDM,306,RC,87177,HCPCS,Outpatient,,,23.1,23.1,,,,,,Other,Not Separately Reimbursable,48.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,48.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,16.86,73,,13.488,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.17,70,,12.936,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.43,19.19,,3.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.55,50,,9.24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.43,48.32,
TEST GIARDIA w/ OC&P,919198,CDM,302,RC,87808,HCPCS,Outpatient,,,165.25,165.25,,,,,,Other,Not Separately Reimbursable,136.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,136.33,82.5,,109.064,percent of total billed charges,Pays at 82.5% of total Billed charges,120.63,73,,96.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.68,70,,92.544,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.71,19.19,,25.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.63,50,,66.104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.71,136.33,
TEST ONLY ROUP B STREP CULTURE VAGINAL,919199,CDM,306,RC,,,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
COUDE CATH 24/5,1003870,CDM,271,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
DRESSING - SORBION 4X4,1004107,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DRESSING - SORBION 18 X 10,1008157,CDM,270,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
LIGA CLIP MED (UROLOGIST),1008258,CDM,272,RC,82533,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CORTISOL SALIVARY,1403263,CDM,305,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
EXTENDED RECOVERY,2000000,CDM,710,RC,,,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,47.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.03,82.5,,37.624,percent of total billed charges,Pays at 82.5% of total Billed charges,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,47.03,
SURGERY 1/2 HOUR,6000030,CDM,360,RC,,,Outpatient,,,1669,1669,,,,,,Other,Not Separately Reimbursable,1376.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1376.93,82.5,,1101.544,percent of total billed charges,Pays at 82.5% of total Billed charges,1218.37,73,,974.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1168.3,70,,934.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,320.28,19.19,,256.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,834.5,50,,667.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,320.28,1376.93,
SURGERY 1 HOUR,6000060,CDM,360,RC,,,Outpatient,,,3337,3337,,,,,,Other,Not Separately Reimbursable,2753.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2753.03,82.5,,2202.424,percent of total billed charges,Pays at 82.5% of total Billed charges,2436.01,73,,1948.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2335.9,70,,1868.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,640.37,19.19,,512.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1668.5,50,,1334.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,640.37,2753.03,
SURGERY 1-1/2 HOUR,6000090,CDM,360,RC,,,Outpatient,,,5006,5006,,,,,,Other,Not Separately Reimbursable,4129.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4129.95,82.5,,3303.96,percent of total billed charges,Pays at 82.5% of total Billed charges,3654.38,73,,2923.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3504.2,70,,2803.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,960.65,19.19,,768.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2503,50,,2002.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,960.65,4129.95,
SURGERY 2 HOURS,6000120,CDM,360,RC,,,Outpatient,,,6674,6674,,,,,,Other,Not Separately Reimbursable,5506.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5506.05,82.5,,4404.84,percent of total billed charges,Pays at 82.5% of total Billed charges,4872.02,73,,3897.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4671.8,70,,3737.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1280.74,19.19,,1024.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3337,50,,2669.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1280.74,5506.05,
SURGERY 2-1/2 HOURS,6000150,CDM,360,RC,,,Outpatient,,,8343,8343,,,,,,Other,Not Separately Reimbursable,6882.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6882.98,82.5,,5506.384,percent of total billed charges,Pays at 82.5% of total Billed charges,6090.39,73,,4872.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5840.1,70,,4672.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1601.02,19.19,,1280.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4171.5,50,,3337.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1601.02,6882.98,
SURGERY 3 HOURS,6000180,CDM,360,RC,,,Outpatient,,,10012,10012,,,,,,Other,Not Separately Reimbursable,8259.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8259.9,82.5,,6607.92,percent of total billed charges,Pays at 82.5% of total Billed charges,7308.76,73,,5847.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7008.4,70,,5606.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1921.3,19.19,,1537.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5006,50,,4004.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1921.3,8259.9,
SURGERY 3-1/2 HOURS,6000210,CDM,360,RC,,,Outpatient,,,11680,11680,,,,,,Other,Not Separately Reimbursable,9636,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9636,82.5,,7708.8,percent of total billed charges,Pays at 82.5% of total Billed charges,8526.4,73,,6821.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8176,70,,6540.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2241.39,19.19,,1793.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5840,50,,4672,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2241.39,9636,
SURGERY 4 HOURS,6000240,CDM,360,RC,,,Outpatient,,,13349,13349,,,,,,Other,Not Separately Reimbursable,11012.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11012.93,82.5,,8810.344,percent of total billed charges,Pays at 82.5% of total Billed charges,9744.77,73,,7795.816,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9344.3,70,,7475.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2561.67,19.19,,2049.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6674.5,50,,5339.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2561.67,11012.93,
SURGERY 4-1/2 HOURS,6000270,CDM,360,RC,,,Outpatient,,,15017,15017,,,,,,Other,Not Separately Reimbursable,12389.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12389.03,82.5,,9911.224,percent of total billed charges,Pays at 82.5% of total Billed charges,10962.41,73,,8769.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10511.9,70,,8409.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2881.76,19.19,,2305.408,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7508.5,50,,6006.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2881.76,12389.03,
SURGERY 5 HOURS,6000300,CDM,360,RC,,,Outpatient,,,16686,16686,,,,,,Other,Not Separately Reimbursable,13765.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13765.95,82.5,,11012.76,percent of total billed charges,Pays at 82.5% of total Billed charges,12180.78,73,,9744.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11680.2,70,,9344.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3202.04,19.19,,2561.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8343,50,,6674.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3202.04,13765.95,
SURGERY 5-1/2 HOURS,6000330,CDM,360,RC,,,Outpatient,,,18355,18355,,,,,,Other,Not Separately Reimbursable,15142.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,15142.88,82.5,,12114.304,percent of total billed charges,Pays at 82.5% of total Billed charges,13399.15,73,,10719.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12848.5,70,,10278.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3522.32,19.19,,2817.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9177.5,50,,7342,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3522.32,15142.88,
SURGERY 6 HOURS,6000360,CDM,360,RC,Q9966,HCPCS,Outpatient,,,20023,20023,,,,,,Other,Not Separately Reimbursable,16518.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16518.98,82.5,,13215.184,percent of total billed charges,Pays at 82.5% of total Billed charges,14616.79,73,,11693.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14016.1,70,,11212.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3842.41,19.19,,3073.928,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10011.5,50,,8009.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3842.41,16518.98,
OMNIPAQUE LOCM 50 ML,6009966,CDM,255,RC,,,Outpatient,,,191,191,,,,,,Other,Not Separately Reimbursable,157.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,157.58,82.5,,126.064,percent of total billed charges,Pays at 82.5% of total Billed charges,139.43,73,,111.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133.7,70,,106.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.65,19.19,,29.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.5,50,,76.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.65,157.58,
PAIN MGT INJECTION,6010100,CDM,360,RC,,,Outpatient,,,1200,1200,,,,,,Other,Not Separately Reimbursable,990,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,990,82.5,,792,percent of total billed charges,Pays at 82.5% of total Billed charges,876,73,,700.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,840,70,,672,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,230.28,19.19,,184.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,600,50,,480,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,230.28,990,
RF ABLATION,6010200,CDM,360,RC,,,Outpatient,,,1800,1800,,,,,,Other,Not Separately Reimbursable,1485,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1485,82.5,,1188,percent of total billed charges,Pays at 82.5% of total Billed charges,1314,73,,1051.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1260,70,,1008,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,345.42,19.19,,276.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,900,50,,720,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,345.42,1485,
LAMINECTOMY AND/OR DISCECTOMY,6010300,CDM,360,RC,,,Outpatient,,,6000,6000,,,,,,Other,Not Separately Reimbursable,4950,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4950,82.5,,3960,percent of total billed charges,Pays at 82.5% of total Billed charges,4380,73,,3504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4200,70,,3360,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1151.4,19.19,,921.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3000,50,,2400,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1151.4,4950,
SHOULDER/KNEE SCOPE/CTR/DEQUARVAINS,6010400,CDM,360,RC,,,Outpatient,,,3600,3600,,,,,,Other,Not Separately Reimbursable,2970,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2970,82.5,,2376,percent of total billed charges,Pays at 82.5% of total Billed charges,2628,73,,2102.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2520,70,,2016,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,690.84,19.19,,552.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1800,50,,1440,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,690.84,2970,
DISC REPLACEMENT; FUSION,6010500,CDM,360,RC,,,Outpatient,,,7200,7200,,,,,,Other,Not Separately Reimbursable,5940,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5940,82.5,,4752,percent of total billed charges,Pays at 82.5% of total Billed charges,5256,73,,4204.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5040,70,,4032,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1381.68,19.19,,1105.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3600,50,,2880,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1381.68,5940,
IMPLANT,6010600,CDM,360,RC,99212,HCPCS,Outpatient,,,10075,10075,,,,,,Other,Not Separately Reimbursable,8311.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8311.88,82.5,,6649.504,percent of total billed charges,Pays at 82.5% of total Billed charges,7354.75,73,,5883.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7052.5,70,,5642,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1933.39,19.19,,1546.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5037.5,50,,4030,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1933.39,8311.88,
Outpatient visit of established patient requiring a physician,6020002,CDM,510,RC,99213,HCPCS,Outpatient,,,204,204,,,,,,Other,Not Separately Reimbursable,168.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,168.3,82.5,,134.64,percent of total billed charges,Pays at 82.5% of total Billed charges,148.92,73,,119.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,142.8,70,,114.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.15,19.19,,31.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102,50,,81.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.15,168.3,
"Established patient office or other outpatient visit, typically 15 minutes",6020004,CDM,510,RC,99214,HCPCS,Outpatient,,,213,213,,,,,,Other,Not Separately Reimbursable,175.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,175.73,82.5,,140.584,percent of total billed charges,Pays at 82.5% of total Billed charges,155.49,73,,124.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.1,70,,119.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.87,19.19,,32.696,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,106.5,50,,85.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.87,175.73,
"Established patient office or other outpatient visit, typically 25 minutes",6020006,CDM,510,RC,99215,HCPCS,Outpatient,,,243,243,,,,,,Other,Not Separately Reimbursable,200.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,200.48,82.5,,160.384,percent of total billed charges,Pays at 82.5% of total Billed charges,177.39,73,,141.912,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.1,70,,136.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.63,19.19,,37.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121.5,50,,97.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.63,200.48,
"Established patient office or other outpatient, visit typically 40 minutes",6020008,CDM,510,RC,20552,HCPCS,Outpatient,,,313,313,,,,,,Other,Not Separately Reimbursable,258.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,258.23,82.5,,206.584,percent of total billed charges,Pays at 82.5% of total Billed charges,228.49,73,,182.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,219.1,70,,175.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.06,19.19,,48.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,156.5,50,,125.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.06,258.23,
INJ SINGLE/MULT TRIG POINT(S) 1 OR 2 MUS,6020552,CDM,360,RC,20553,HCPCS,Outpatient,,,108,108,,,,,,Other,Not Separately Reimbursable,89.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,89.1,82.5,,71.28,percent of total billed charges,Pays at 82.5% of total Billed charges,78.84,73,,63.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75.6,70,,60.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.73,19.19,,16.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54,50,,43.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.73,89.1,
Injection of medication into an area that triggers pain,6020553,CDM,360,RC,20610,HCPCS,Outpatient,,,728,728,,,,,,Other,Not Separately Reimbursable,600.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,600.6,82.5,,480.48,percent of total billed charges,Pays at 82.5% of total Billed charges,531.44,73,,425.152,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,509.6,70,,407.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.7,19.19,,111.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,364,50,,291.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.7,600.6,
Draining or injecting medication into a major joint/bursa without ultrasound,6020610,CDM,360,RC,20611,HCPCS,Outpatient,,,728,728,,,,,,Other,Not Separately Reimbursable,600.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,600.6,82.5,,480.48,percent of total billed charges,Pays at 82.5% of total Billed charges,531.44,73,,425.152,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,509.6,70,,407.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.7,19.19,,111.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,364,50,,291.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.7,600.6,
ARTHROCESPIRA/INJ; MAJ JNT/BUR W/US,6020611,CDM,360,RC,27096,HCPCS,Outpatient,,,850,850,,,,,,Other,Not Separately Reimbursable,701.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,701.25,82.5,,561,percent of total billed charges,Pays at 82.5% of total Billed charges,620.5,73,,496.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595,70,,476,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.12,19.19,,130.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,425,50,,340,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.12,701.25,
INJ SACROILIAC JOINT,6027096,CDM,360,RC,29125,HCPCS,Outpatient,,,909,909,,,,,,Other,Not Separately Reimbursable,749.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,749.93,82.5,,599.944,percent of total billed charges,Pays at 82.5% of total Billed charges,663.57,73,,530.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,636.3,70,,509.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.44,19.19,,139.552,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,454.5,50,,363.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.44,749.93,
APPLY FOREARM SPLINT,6029125,CDM,360,RC,62270,HCPCS,Outpatient,,,376,376,,,,,,Other,Not Separately Reimbursable,310.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,310.2,82.5,,248.16,percent of total billed charges,Pays at 82.5% of total Billed charges,274.48,73,,219.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,263.2,70,,210.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.15,19.19,,57.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,188,50,,150.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.15,310.2,
SPINAL PUNCTURE LUMBAR DIAGNOSTIC,6062270,CDM,360,RC,62273,HCPCS,Outpatient,,,998,998,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,728.54,73,,582.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,698.6,70,,558.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191.52,19.19,,153.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,499,50,,399.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191.52,982.8,
INJ EDPIDURAL BLOOD PATCH,6062273,CDM,360,RC,62284,HCPCS,Outpatient,,,1951,1951,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1424.23,73,,1139.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1365.7,70,,1092.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,19.19,,299.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,975.5,50,,780.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,1424.23,
INJECTION FOR MYELOGRAM,6062284,CDM,360,RC,62320,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,1508.85,
INJECT SPINE CERVICAL/THORACIC,6062320,CDM,360,RC,62321,HCPCS,Outpatient,,,2072,2072,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1512.56,73,,1210.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1450.4,70,,1160.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,397.62,19.19,,318.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1036,50,,828.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,397.62,1512.56,
INJECT SPINE CERVICAL/THORACIC W/IMAGING,6062321,CDM,360,RC,62322,HCPCS,Outpatient,,,2425,2425,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1770.25,73,,1416.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1697.5,70,,1358,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,465.36,19.19,,372.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1212.5,50,,970,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,465.36,1770.25,
Injection of substance into spinal canal of lower back or sacrum using imaging guidance,6062322,CDM,360,RC,62323,HCPCS,Outpatient,,,1951,1951,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1424.23,73,,1139.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1365.7,70,,1092.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,19.19,,299.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,975.5,50,,780.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,1424.23,
Injection of substance into spinal canal of lower back or sacrum using imaging guidance,6062323,CDM,360,RC,62368,HCPCS,Outpatient,,,2301,2301,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1679.73,73,,1343.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1610.7,70,,1288.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,441.56,19.19,,353.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1150.5,50,,920.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,441.56,1679.73,
ANALYZE SP INF PUMP W/REPROG,6062368,CDM,360,RC,63650,HCPCS,Outpatient,,,786,786,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,573.78,73,,459.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,550.2,70,,440.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,150.83,19.19,,120.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,393,50,,314.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,150.83,1319.85,
PERCUTANEOUS IMPLANTATION NEUROSTIMULATO,6063650,CDM,360,RC,63685,HCPCS,Outpatient,,,18167,18167,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,13261.91,73,,10609.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12716.9,70,,10173.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3486.25,19.19,,2789,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9083.5,50,,7266.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1319.85,13261.91,
INSERTION/REPLACEMENT SPINAL NEURO PULSE,6063685,CDM,360,RC,64421,HCPCS,Outpatient,,,48140,48140,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,35142.2,73,,28113.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33698,70,,26958.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9238.07,19.19,,7390.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24070,50,,19256,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1319.85,35142.2,
NERVE BLOCK INTERCOSTAL MULT REGIONAL,6064421,CDM,360,RC,64445,HCPCS,Outpatient,,,1951,1951,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1424.23,73,,1139.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1365.7,70,,1092.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,19.19,,299.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,975.5,50,,780.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,1424.23,
"NERVE BLOCK SCIATIC NERVE, SINGLE",6064445,CDM,360,RC,64450,HCPCS,Outpatient,,,1951,1951,,,,,,Other,Not Separately Reimbursable,1609.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1609.58,82.5,,1287.664,percent of total billed charges,Pays at 82.5% of total Billed charges,1424.23,73,,1139.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1365.7,70,,1092.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,19.19,,299.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,975.5,50,,780.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,1609.58,
NERVE BLOCK OTHER PERIPHERAL NERV BRANCH,6064450,CDM,360,RC,64479,HCPCS,Outpatient,,,998,998,,,,,,Other,Not Separately Reimbursable,823.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,823.35,82.5,,658.68,percent of total billed charges,Pays at 82.5% of total Billed charges,728.54,73,,582.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,698.6,70,,558.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191.52,19.19,,153.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,499,50,,399.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191.52,823.35,
INJ W/IMAGING GUID CERVICAL THORACIC SGL,6064479,CDM,360,RC,64483,HCPCS,Outpatient,,,1951,1951,,,,,,Other,Not Separately Reimbursable,1609.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1609.58,82.5,,1287.664,percent of total billed charges,Pays at 82.5% of total Billed charges,1424.23,73,,1139.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1365.7,70,,1092.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,19.19,,299.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,975.5,50,,780.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,1609.58,
Injections of anesthetic and/or steroid drug into lower or sacral spine nerve root using imaging guidance,6064483,CDM,360,RC,64484,HCPCS,Outpatient,,,1951,1951,,,,,,Other,Not Separately Reimbursable,1609.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1609.58,82.5,,1287.664,percent of total billed charges,Pays at 82.5% of total Billed charges,1424.23,73,,1139.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1365.7,70,,1092.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,19.19,,299.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,975.5,50,,780.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,1609.58,
INJ FORAMEN EPID L/S EACH ADD'L LEVEL,6064484,CDM,360,RC,64490,HCPCS,Outpatient,,,1122,1122,,,,,,Other,Not Separately Reimbursable,925.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,925.65,82.5,,740.52,percent of total billed charges,Pays at 82.5% of total Billed charges,819.06,73,,655.248,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,785.4,70,,628.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,215.31,19.19,,172.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,561,50,,448.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,215.31,925.65,
INJ PARAVERT F JNT C/T 1 LEV,6064490,CDM,360,RC,64491,HCPCS,Outpatient,,,1951,1951,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1424.23,73,,1139.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1365.7,70,,1092.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,19.19,,299.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,975.5,50,,780.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,1424.23,
INJ PARAVERT F JNT C/T 2 LEV,6064491,CDM,360,RC,64492,HCPCS,Outpatient,,,728,728,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,531.44,73,,425.152,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,509.6,70,,407.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.7,19.19,,111.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,364,50,,291.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.7,982.8,
INJ PARAVERT F JNT C/T 3 LEV,6064492,CDM,360,RC,64493,HCPCS,Outpatient,,,728,728,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,531.44,73,,425.152,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,509.6,70,,407.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.7,19.19,,111.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,364,50,,291.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.7,982.8,
Injection into lower back of nerve block using imaging guidance,6064493,CDM,360,RC,64494,HCPCS,Outpatient,,,1951,1951,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1424.23,73,,1139.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1365.7,70,,1092.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,19.19,,299.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,975.5,50,,780.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,1424.23,
INJ PARAVERT F JNT L/S 2 LEV,6064494,CDM,360,RC,64495,HCPCS,Outpatient,,,728,728,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,531.44,73,,425.152,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,509.6,70,,407.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.7,19.19,,111.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,364,50,,291.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.7,982.8,
INJ PARAVERT F JNT L/S 2 LEV,6064495,CDM,360,RC,64510,HCPCS,Outpatient,,,728,728,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,531.44,73,,425.152,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,509.6,70,,407.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.7,19.19,,111.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,364,50,,291.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.7,982.8,
NERVE BLOCK STELLATE GANGLION,6064510,CDM,360,RC,64520,HCPCS,Outpatient,,,1951,1951,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1424.23,73,,1139.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1365.7,70,,1092.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,19.19,,299.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,975.5,50,,780.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,1424.23,
"INJECTION, ANESTH AGENT, LUMBAR/THORACIC",6064520,CDM,360,RC,64530,HCPCS,Outpatient,,,1951,1951,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1424.23,73,,1139.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1365.7,70,,1092.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,19.19,,299.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,975.5,50,,780.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.4,1424.23,
"INJ, ANES AGENT; CELIAC PLEXUS",6064530,CDM,360,RC,64635,HCPCS,Outpatient,,,2017,2017,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1472.41,73,,1177.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1411.9,70,,1129.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,387.06,19.19,,309.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1008.5,50,,806.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,387.06,1472.41,
DESTR PARAVERTEBRL NERVE L/S,6064622,CDM,360,RC,64636,HCPCS,Outpatient,,,3085,3085,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,2252.05,73,,1801.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2159.5,70,,1727.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,592.01,19.19,,473.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1542.5,50,,1234,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,592.01,2252.05,
"LUMBAR OR SACRAL, EACH ADD FACET JOINT",6064623,CDM,360,RC,64634,HCPCS,Outpatient,,,1952,1952,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1424.96,73,,1139.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1366.4,70,,1093.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.59,19.19,,299.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,976,50,,780.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.59,1424.96,
"CERVICAL THORACIC RADIOFREQ, EA ADD LEV",6064627,CDM,360,RC,64633,HCPCS,Outpatient,,,823,823,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,600.79,73,,480.632,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,576.1,70,,460.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.93,19.19,,126.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,411.5,50,,329.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.93,982.8,
DESTROY CERVICAL THORACIC SINGLE JOINT,6064633,CDM,360,RC,64634,HCPCS,Outpatient,,,1936,1936,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1413.28,73,,1130.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1355.2,70,,1084.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371.52,19.19,,297.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,968,50,,774.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371.52,1413.28,
DESTROY CERVICAL THORACIC EA ADD JOINT,6064634,CDM,360,RC,64635,HCPCS,Outpatient,,,719,719,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,524.87,73,,419.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,503.3,70,,402.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.98,19.19,,110.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,359.5,50,,287.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.98,982.8,
NEUROLYSIS LUMBAR SACRAL SINGLE JOINT,6064635,CDM,360,RC,64636,HCPCS,Outpatient,,,3085,3085,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,2252.05,73,,1801.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2159.5,70,,1727.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,592.01,19.19,,473.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1542.5,50,,1234,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,592.01,2252.05,
NEUROLYSIS LUMBAR SACRAL EACH ADD JOINT,6064636,CDM,360,RC,64640,HCPCS,Outpatient,,,1952,1952,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1424.96,73,,1139.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1366.4,70,,1093.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.59,19.19,,299.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,976,50,,780.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,374.59,1424.96,
GENICULAR NERVE BLOCK,6064640,CDM,360,RC,96360,HCPCS,Outpatient,,,2017,2017,,,,,,Other,Not Separately Reimbursable,1664.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1664.03,82.5,,1331.224,percent of total billed charges,Pays at 82.5% of total Billed charges,1472.41,73,,1177.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1411.9,70,,1129.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,387.06,19.19,,309.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1008.5,50,,806.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,387.06,1664.03,
HYDRATION IV INFUSION; INITITAL,6090760,CDM,360,RC,96365,HCPCS,Outpatient,,,343,343,,,,,,Other,Not Separately Reimbursable,282.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,282.98,82.5,,226.384,percent of total billed charges,Pays at 82.5% of total Billed charges,250.39,73,,200.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,240.1,70,,192.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.82,19.19,,52.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,171.5,50,,137.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.82,282.98,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",6090765,CDM,360,RC,96366,HCPCS,Outpatient,,,319,319,,,,,,Other,Not Separately Reimbursable,263.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,263.18,82.5,,210.544,percent of total billed charges,Pays at 82.5% of total Billed charges,232.87,73,,186.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,223.3,70,,178.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.22,19.19,,48.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,159.5,50,,127.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.22,263.18,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",6090766,CDM,360,RC,96367,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,54.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,54.45,82.5,,43.56,percent of total billed charges,Pays at 82.5% of total Billed charges,48.18,73,,38.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.2,70,,36.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,19.19,,10.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33,50,,26.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,54.45,
"INFUSION, IV SEQUENTIAL DRUG",6090767,CDM,360,RC,96372,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,54.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,54.45,82.5,,43.56,percent of total billed charges,Pays at 82.5% of total Billed charges,48.18,73,,38.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.2,70,,36.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,19.19,,10.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33,50,,26.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,54.45,
"INJECTION, SC/IM",6090772,CDM,360,RC,96374,HCPCS,Outpatient,,,106,106,,,,,,Other,Not Separately Reimbursable,87.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,87.45,82.5,,69.96,percent of total billed charges,Pays at 82.5% of total Billed charges,77.38,73,,61.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.2,70,,59.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.34,19.19,,16.272,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53,50,,42.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.34,87.45,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",6090774,CDM,360,RC,96375,HCPCS,Outpatient,,,131,131,,,,,,Other,Not Separately Reimbursable,108.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,108.08,82.5,,86.464,percent of total billed charges,Pays at 82.5% of total Billed charges,95.63,73,,76.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.7,70,,73.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.14,19.19,,20.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.5,50,,52.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.14,108.08,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",6090775,CDM,360,RC,,,Outpatient,,,131,131,,,,,,Other,Not Separately Reimbursable,108.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,108.08,82.5,,86.464,percent of total billed charges,Pays at 82.5% of total Billed charges,95.63,73,,76.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.7,70,,73.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.14,19.19,,20.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.5,50,,52.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.14,108.08,
INTRA-OPERATIVE NEURO MONITORING-LOP,6095900,CDM,360,RC,,,Outpatient,,,1100,1100,,,,,,Other,Not Separately Reimbursable,907.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,907.5,82.5,,726,percent of total billed charges,Pays at 82.5% of total Billed charges,803,73,,642.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,770,70,,616,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,211.09,19.19,,168.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,550,50,,440,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,211.09,907.5,
INTRA-OPERATIVE NEURO MONITORING,6095901,CDM,360,RC,95972,HCPCS,Outpatient,,,880,880,,,,,,Other,Not Separately Reimbursable,726,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,726,82.5,,580.8,percent of total billed charges,Pays at 82.5% of total Billed charges,642.4,73,,513.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,616,70,,492.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,168.87,19.19,,135.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,440,50,,352,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,168.87,726,
EVAL IMPLANTED NEUROSTIMULATOR,6095972,CDM,921,RC,97602,HCPCS,Outpatient,,,346,346,,,,,,Other,Not Separately Reimbursable,285.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,285.45,82.5,,228.36,percent of total billed charges,Pays at 82.5% of total Billed charges,252.58,73,,202.064,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,242.2,70,,193.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.4,19.19,,53.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,173,50,,138.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.4,285.45,
MAGGOT THERAPY-ACTIVE WND CARE NON-SELEC,6097602,CDM,510,RC,99151,HCPCS,Outpatient,,,890,890,,,,,,Other,Not Separately Reimbursable,734.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,734.25,82.5,,587.4,percent of total billed charges,Pays at 82.5% of total Billed charges,649.7,73,,519.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,623,70,,498.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,19.19,,136.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,445,50,,356,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,734.25,
MOD CS BY SAME PHYS < 5 YRS INITIAL :15,6099151,CDM,370,RC,99152,HCPCS,Outpatient,,,258,258,,,,,,Other,Not Separately Reimbursable,212.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,212.85,82.5,,170.28,percent of total billed charges,Pays at 82.5% of total Billed charges,188.34,73,,150.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.6,70,,144.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.51,19.19,,39.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,129,50,,103.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.51,212.85,
MOD CS BY SAME PHYS 5 YRS + INITIAL 15M,6099152,CDM,370,RC,99153,HCPCS,Outpatient,,,258,258,,,,,,Other,Not Separately Reimbursable,212.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,212.85,82.5,,170.28,percent of total billed charges,Pays at 82.5% of total Billed charges,188.34,73,,150.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.6,70,,144.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.51,19.19,,39.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,129,50,,103.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.51,212.85,
MOD CS BY SAME PHYS EA ADD'L 15 MIN,6099153,CDM,370,RC,G0378,HCPCS,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,25.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,25.58,82.5,,20.464,percent of total billed charges,Pays at 82.5% of total Billed charges,22.63,73,,18.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.7,70,,17.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,19.19,,4.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.5,50,,12.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,25.58,
OBSERVATION; PER HOUR,7010540,CDM,762,RC,,,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,28.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.88,82.5,,23.104,percent of total billed charges,Pays at 82.5% of total Billed charges,25.55,73,,20.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,70,,19.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,19.19,,5.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,50,,14,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,28.88,
RECOVERY; O-30 MIN,9010512,CDM,710,RC,,,Outpatient,,,579,579,,,,,,Other,Not Separately Reimbursable,477.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,477.68,82.5,,382.144,percent of total billed charges,Pays at 82.5% of total Billed charges,422.67,73,,338.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,405.3,70,,324.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.11,19.19,,88.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,289.5,50,,231.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.11,477.68,
RECOVERY; EACH ADD'L 30 MIN,9010520,CDM,710,RC,87255,HCPCS,Outpatient,,,116,116,,,,,,Other,Not Separately Reimbursable,95.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,95.7,82.5,,76.56,percent of total billed charges,Pays at 82.5% of total Billed charges,84.68,73,,67.744,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.2,70,,64.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.26,19.19,,17.808,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58,50,,46.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.26,95.7,
TEST HERPES SIMPLEX VIRUS CUL,9191988,CDM,306,RC,,,Outpatient,,,68,68,,,,,,Other,Not Separately Reimbursable,56.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.1,82.5,,44.88,percent of total billed charges,Pays at 82.5% of total Billed charges,49.64,73,,39.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.6,70,,38.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,19.19,,10.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34,50,,27.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,56.1,
STYLET INTUBATION 12F,10001019,CDM,270,RC,,,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
BLADE LAR MAC #3,10001020,CDM,270,RC,,,Outpatient,,,820,820,,,,,,Other,Not Separately Reimbursable,676.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,676.5,82.5,,541.2,percent of total billed charges,Pays at 82.5% of total Billed charges,598.6,73,,478.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,574,70,,459.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.36,19.19,,125.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,410,50,,328,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.36,676.5,
TRAY THORACENTESIS,10002005,CDM,271,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
TRAY SPINAL ANESTHESIA,10002006,CDM,271,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
TRAY EPIDURAL (DR. SHORES),10002007,CDM,271,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
TRAY PARACENTESIS,10002009,CDM,271,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
CATH COUDE 14 FR,10003864,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
COUDE CATH 16 FRENCH,10003868,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
COUDE CATH 20/5,10003869,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
COUDE CATH 22/5,10003870,CDM,271,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
COUDE CATH 24/30,10003871,CDM,271,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
DRESSING - SILVERSORB GEL,10003998,CDM,270,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
DRESSING - SILVERSORB 4X4,10003999,CDM,270,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
VAC ATS CONNECTORW/TUBING,10004000,CDM,271,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
VAC TRAC PAD,10004001,CDM,270,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
VAC GRANUFOAM DRS MD,10004002,CDM,271,RC,,,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,165,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,165,82.5,,132,percent of total billed charges,Pays at 82.5% of total Billed charges,146,73,,116.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,70,,112,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,19.19,,30.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100,50,,80,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,165,
VAC CANISTER W/GEL,10004003,CDM,271,RC,,,Outpatient,,,170,170,,,,,,Other,Not Separately Reimbursable,140.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,140.25,82.5,,112.2,percent of total billed charges,Pays at 82.5% of total Billed charges,124.1,73,,99.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,119,70,,95.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.62,19.19,,26.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85,50,,68,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.62,140.25,
VAC VERSAFOAM DRESSING,10004004,CDM,271,RC,,,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,165,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,165,82.5,,132,percent of total billed charges,Pays at 82.5% of total Billed charges,146,73,,116.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,70,,112,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,19.19,,30.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100,50,,80,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,165,
DRESSING - MAXORB 4X8 SILVER,10004010,CDM,271,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
DRESSING - MAXORB 2X2,10004011,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - PURACAL PLUS COLLAGEN,10004019,CDM,271,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
DRESSING - PROMOGRAN PRISMA,10004020,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
DRESSING - TEGADERM 4X4,10004022,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - MEDIPORE 4X6,10004024,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - MEDIPORE 4X4,10004025,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - MEDIPORE 2.5 X 4,10004026,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - VERSAFOAM,10004028,CDM,271,RC,,,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
DRESSING - GRANUFOAM KCI,10004029,CDM,271,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
DRESSING - POLYMEM 4X4,10004031,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SURESITE 6X8,10004032,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DRESSING - TEGADERM ABSORBENT 90800,10004038,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRESSING - TEGADERM ABSORBENT 6X8,10004039,CDM,271,RC,,,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
DRESSING - TEGADERM 8X12,10004040,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - TEGADERM 6X8,10004041,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - SKIN REPAIR CREAM,10004055,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRESSING - HYDROGEL GAUZE 4X4,10004056,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - CALAZINE PASTE,10004057,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
DRESSING - MAXORB ROPE /CALCIUM ALGINATE,10004058,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRESSING - MAXORB ROPE - SILVER ALGINATE,10004059,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
DRESSING - STRATASORB 6X8,10004062,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DRESSING - BORDER GAUZE 6X6,10004063,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - BORDER GAUZE 4X4,10004065,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - MAXORB 4X8,10004067,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
DRESSING - MAXORB 4X4 CAL A/G,10004068,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRESSING - SKIN PASTE,10004069,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DRESSING - BORDER GAUZE 2X2,10004071,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - AQUACELL 8X12 (SILVER),10004072,CDM,270,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
DRESSING - AQUACEL 4X4,10004073,CDM,270,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRESSING - AQUACEL EXTRA 4X5,10004074,CDM,270,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRESSING - OPTICELL AG,10004075,CDM,270,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
DRESSING - AQUACEL EXTRA 2X2,10004076,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - AQUACEL .75 X18 RIBBON,10004079,CDM,270,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
DRESSING - AQUACEL 2/5 X18 RIBBON HYFBR,10004080,CDM,270,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRESSING - AQUACEL AG 4X4 420642,10004081,CDM,270,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DRESSING - NUTRASHIELD MOISTURE BARRIER,10004082,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
DRESSING - AQUACEL AG .39X18 RIBBON,10004083,CDM,270,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
DRESSING - AQUACEL 3/4 X18 RIBBON HYFBR,10004084,CDM,270,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRESSING - OASIS WOUND MATRIX 3X3.5,10004088,CDM,271,RC,,,Outpatient,,,350,350,,,,,,Other,Not Separately Reimbursable,288.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,288.75,82.5,,231,percent of total billed charges,Pays at 82.5% of total Billed charges,255.5,73,,204.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245,70,,196,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.17,19.19,,53.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,50,,140,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.17,288.75,
DRESSING - DRAWTEX 6X8,10004089,CDM,271,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
DRESSING - COMBIDERM 5X5 AQUACELL,10004090,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRESSING - COMBIDERM 4X4 AQUACELL,10004091,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRESSING - COMBIDERM ROPE AQUACELL,10004092,CDM,271,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
DRESSING - AQUACEL (BRDR) AG 4X4 420805,10004098,CDM,270,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DRESSING - SKINTEGRITY GEL (HYDROGEL),10004099,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DRESSING - HYDROGEL SILVER (TUBE),10004101,CDM,271,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
DRESSING - ACTICOAT 3 4X4,10004102,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
DRESSING - ACTICOAT 7 4X4,10004103,CDM,271,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
DRESSING - ACTICOAT ABSORBENT,10004104,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
DRESSING - ACTICOAT MOISTURE CONTROL,10004105,CDM,271,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
DRESSING - IODOSORB,10004106,CDM,271,RC,,,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,165,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,165,82.5,,132,percent of total billed charges,Pays at 82.5% of total Billed charges,146,73,,116.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,70,,112,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,19.19,,30.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100,50,,80,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,165,
DRESSING - MEPITEL ONE 5 X7.5,10004107,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
DRESSING - MEDI HONEY 2X2,10004108,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DRESSING - CUTIMED SILTEC 3X3,10004110,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DRESSING - CUTIMED SILTEC 6X6,10004111,CDM,271,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
DRESSING - CUTIMED WCL 4X8,10004112,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
DRESSING - CUTIMED HYDROACTIVE 5.5X5.5,10004113,CDM,271,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
DRESSING - CUTIMED HYDROACTIVE 2.8X3.3,10004114,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
DRESSING - MEPILEX SACRUM 8.7'X9.8,10004115,CDM,271,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
DRESSING - LEUKOMED SORBACT,10004116,CDM,271,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
DRESSING - LEUKOMED SORBACT 3X6,10004117,CDM,271,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
DRESSING - OPTILOCK,10004118,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - SILVERLON WHI,10004120,CDM,271,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
DRESSING - SILVERLON NEG PRESSURE,10004121,CDM,271,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
DRESSING - HYDROFERA BLUE,10004122,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
DRESSING - LEUKOMED SORBACT 3X4,10004123,CDM,271,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
DRESSING - IODOSORB (TUBE),10004144,CDM,271,RC,,,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
SKINTEGRITY - SKIN CLEANSER 8OZ,10004153,CDM,270,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRESSING - GELFOAM (DR. WALL,10004199,CDM,271,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
LAVACUATOR 36 FR,10007008,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
LAVACUATOR 18 FR,10007009,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
LAVACUATOR 22 FR,10007010,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
LAVACUATOR 28 FR,10007011,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
LAVACUATOR 32 FR,10007012,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
COUDE CATH 26,10008370,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
INTUBATION,10012816,CDM,271,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
SUCTION,10012830,CDM,271,RC,28291,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
PODIATRY - HINGE TOE IMPLANT SIZE 4,10028291,CDM,272,RC,,,Outpatient,,,2800,2800,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,2044,73,,1635.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1960,70,,1568,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,537.32,19.19,,429.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1400,50,,1120,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,537.32,2044,
DRESSING - XEROFORM 5X9,10032727,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ARM BOARD LONG,10080025,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ARM BOARD SHORT,10080026,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ABD PADS EACH (36/BX),10080050,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ABDOMINAL BINDER 12,10080100,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
ABDOMINAL BINDER 10,10080101,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
ABDOMINAL BINDER 8,10080102,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
ABDOMINAL BINDER UNIVERSAL,10080103,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
BANDAGE ES MARK 4,10080123,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
BANDAGE ES MARK 6,10080124,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
BANDAGE ACE 2,10080125,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
BANDAGE ACE 3,10080126,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
BANDAGE ACE 4,10080128,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
BANDAGE ACE 6,10080129,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CATHETER - WORD,10080130,CDM,272,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
BANDAGE JOBST COMPRIFORE COMPRESSION,10080132,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
BANDAGE JOBST COMPRIFORE COMPRESSION LTE,10080133,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
TURN & POSITION SYSTEM,10080139,CDM,271,RC,,,Outpatient,,,460,460,,,,,,Other,Not Separately Reimbursable,379.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,379.5,82.5,,303.6,percent of total billed charges,Pays at 82.5% of total Billed charges,335.8,73,,268.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,322,70,,257.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.27,19.19,,70.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,230,50,,184,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.27,379.5,
PANTIES MESH (DRESSING RETENTION),10080142,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - ADAPTIC TOUCH 3X4.25,10080149,CDM,270,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
DRESSING - ADAPTIC PKG 3X8,10080150,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - ADAPTIC PKG 3X3,10080151,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - BIO PATCH,10080152,CDM,270,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
DRESSING TRAUMA 10X30,10080153,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - OPSITE 4X8,10080154,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - SORBION 4 X 8,10080155,CDM,270,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DRESSING - SORBION 4 X 4,10080156,CDM,270,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRESSING - MESALT 3 X3,10080157,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
AIRWAYS,10080200,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
AIRWAY-NASOPHYARYNGEAL 20,10080201,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
AIRWAY-NASOPHYARYNGEAL 16,10080202,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
AIRWAY-NASOPHYARYNGEAL 22,10080203,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
AIRWAY-NASOPHYARYNGEAL 24,10080222,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
AIRWAY-NASOPHYARYNGEAL 26,10080223,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
AIRWAY-NASOPHYARYNGEAL 12,10080224,CDM,272,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
AIRWAY-NASOPHYARYNGEAL 6.0,10080250,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
NASAL ASPIRATOR,10080251,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
AIRWAY-NASOPHYARYNGEAL 7.0 / 7.5,10080252,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
AIRWAY-NASOPHYARYNGEAL 8.0 / 8.5,10080253,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
AIRWAY-NASOPHYARYNGEAL 9.0,10080254,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
AIRWAY-NASOPHYARYNGEAL PED 12FR,10080255,CDM,272,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
AIRWAY-NASOPHYARYNGEAL PED 40MM,10080256,CDM,272,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
AIRWAY-ZOLL PED/ADULT,10080257,CDM,272,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
AIRWAY-NASOPHYARYNGEAL 30 FR,10080258,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
AIRWAY-NASOPHYARYNGEAL 28 FR,10080259,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
AIRWAY-NASOPHYARYNGEAL ADJUSTABLE FLG 20,10080260,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
AIRWAY-NASOPHYARYNGEAL ADJUSTABLE FLG 22,10080261,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
AIRWAY-NASOPHYARYNGEAL ADJUSTABLE FLG 24,10080262,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ARM SLING XSMALL,10080275,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
ARM SLING SM,10080276,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ARM SLING MEDIUM,10080277,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
ARM SLING LG,10080278,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
ANESTH KIT VENOSET #1884,10080300,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
TRI-LUMEN TRAY 16MM ECVC2730,10080303,CDM,272,RC,,,Outpatient,,,380,380,,,,,,Other,Not Separately Reimbursable,313.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,313.5,82.5,,250.8,percent of total billed charges,Pays at 82.5% of total Billed charges,277.4,73,,221.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,266,70,,212.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.92,19.19,,58.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,190,50,,152,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.92,313.5,
CATHETER - BARD PORT,10080305,CDM,272,RC,,,Outpatient,,,870,870,,,,,,Other,Not Separately Reimbursable,717.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,717.75,82.5,,574.2,percent of total billed charges,Pays at 82.5% of total Billed charges,635.1,73,,508.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,609,70,,487.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.95,19.19,,133.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,435,50,,348,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.95,717.75,
GRAFT - ARTEGRAFT VASUCULAR,10080306,CDM,278,RC,,,Outpatient,,,2610,2610,,,,,,Other,Not Separately Reimbursable,2610,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2610,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1905.3,73,,1524.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1827,70,,1461.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,500.86,19.19,,400.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1305,50,,1044,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,500.86,2610,
TRI-LUMEN TRAY 20MM ECVC375,10080310,CDM,272,RC,,,Outpatient,,,380,380,,,,,,Other,Not Separately Reimbursable,313.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,313.5,82.5,,250.8,percent of total billed charges,Pays at 82.5% of total Billed charges,277.4,73,,221.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,266,70,,212.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.92,19.19,,58.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,190,50,,152,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.92,313.5,
TRAY ARTERIAL CATH 20GA 1 3/4,10080311,CDM,272,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
KIT RADIOFREQUENCY SINGLE PROBE,10080314,CDM,272,RC,,,Outpatient,,,3770,3770,,,,,,Other,Not Separately Reimbursable,3110.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3110.25,82.5,,2488.2,percent of total billed charges,Pays at 82.5% of total Billed charges,2752.1,73,,2201.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2639,70,,2111.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,723.46,19.19,,578.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1885,50,,1508,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,723.46,3110.25,
TUBE J- GUIDEWIRE 9FR,10080315,CDM,272,RC,,,Outpatient,,,270,270,,,,,,Other,Not Separately Reimbursable,222.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,222.75,82.5,,178.2,percent of total billed charges,Pays at 82.5% of total Billed charges,197.1,73,,157.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,189,70,,151.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.81,19.19,,41.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,135,50,,108,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.81,222.75,
PEG KIT 20 FR,10080329,CDM,272,RC,,,Outpatient,,,1170,1170,,,,,,Other,Not Separately Reimbursable,965.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,965.25,82.5,,772.2,percent of total billed charges,Pays at 82.5% of total Billed charges,854.1,73,,683.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,819,70,,655.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,224.52,19.19,,179.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,585,50,,468,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,224.52,965.25,
PEG KIT 18 FR,10080330,CDM,272,RC,,,Outpatient,,,1060,1060,,,,,,Other,Not Separately Reimbursable,874.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,874.5,82.5,,699.6,percent of total billed charges,Pays at 82.5% of total Billed charges,773.8,73,,619.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,742,70,,593.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.41,19.19,,162.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,530,50,,424,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.41,874.5,
PEG KIT 24FR GJ,10080333,CDM,272,RC,,,Outpatient,,,1240,1240,,,,,,Other,Not Separately Reimbursable,1023,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1023,82.5,,818.4,percent of total billed charges,Pays at 82.5% of total Billed charges,905.2,73,,724.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,868,70,,694.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,237.96,19.19,,190.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,620,50,,496,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,237.96,1023,
FLUID PRESSURE INFUSER 1000ML,10080556,CDM,271,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
URINARY DRAIN BAG-BEDSIDE,10080650,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
SUCTION CATHETER KIT 16FR,10080752,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
BUCKS TRACT W/HEEL PROTE SMALL,10080800,CDM,270,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
BUCKS TRACTION MEDIUM,10080801,CDM,270,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
BUCKS TRACTION LARGE,10080802,CDM,270,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
BUCKS TRACTION XLARGE,10080803,CDM,270,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
BUTTERFLY 16GA,10080895,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
BUTTERFLY 23GA,10080902,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ANESTHESIA/BREATHING CIRCUITS AU304,10080950,CDM,272,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
ANES PEDI BREATHING CIRCUITS,10080951,CDM,272,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
ANES INFANT BREATHING CIRCUITS,10080952,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ANESTHESIA TRANSDUCER BLOOD PRESSURE DIS,10080953,CDM,272,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
ANESTHESIA ARTHERY CATH SET 20G X 1-3/4,10080954,CDM,272,RC,,,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
ANESTHESIA GLIDESCOPE SPECTRUM LOPRO S3,10080955,CDM,272,RC,,,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
ANESTHESIA GLIDESCOPE BFLEX 5.0 BRONCHOS,10080956,CDM,272,RC,,,Outpatient,,,1180,1180,,,,,,Other,Not Separately Reimbursable,973.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,973.5,82.5,,778.8,percent of total billed charges,Pays at 82.5% of total Billed charges,861.4,73,,689.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,826,70,,660.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,226.44,19.19,,181.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,590,50,,472,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,226.44,973.5,
ORTHO FIBULA PLATE LEFT DISTAL,10081100,CDM,271,RC,,,Outpatient,,,3880,3880,,,,,,Other,Not Separately Reimbursable,3201,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3201,82.5,,2560.8,percent of total billed charges,Pays at 82.5% of total Billed charges,2832.4,73,,2265.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2716,70,,2172.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,744.57,19.19,,595.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1940,50,,1552,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,744.57,3201,
ORTHO 3.5 16MM N/L SCREW,10081101,CDM,271,RC,,,Outpatient,,,810,810,,,,,,Other,Not Separately Reimbursable,668.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,668.25,82.5,,534.6,percent of total billed charges,Pays at 82.5% of total Billed charges,591.3,73,,473.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,567,70,,453.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,19.19,,124.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,405,50,,324,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,668.25,
ORTHO 3.5 12MM N/L SCREW,10081102,CDM,271,RC,,,Outpatient,,,810,810,,,,,,Other,Not Separately Reimbursable,668.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,668.25,82.5,,534.6,percent of total billed charges,Pays at 82.5% of total Billed charges,591.3,73,,473.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,567,70,,453.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,19.19,,124.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,405,50,,324,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,668.25,
ORTHO 4.0 12MM N/L SCREW,10081103,CDM,271,RC,,,Outpatient,,,810,810,,,,,,Other,Not Separately Reimbursable,668.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,668.25,82.5,,534.6,percent of total billed charges,Pays at 82.5% of total Billed charges,591.3,73,,473.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,567,70,,453.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,19.19,,124.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,405,50,,324,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,668.25,
ORTHO 3.5 12MM LOCK SCREW,10081104,CDM,271,RC,,,Outpatient,,,810,810,,,,,,Other,Not Separately Reimbursable,668.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,668.25,82.5,,534.6,percent of total billed charges,Pays at 82.5% of total Billed charges,591.3,73,,473.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,567,70,,453.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,19.19,,124.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,405,50,,324,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,668.25,
ORTHO 3.5 8MM LOCK SCREW,10081105,CDM,271,RC,,,Outpatient,,,810,810,,,,,,Other,Not Separately Reimbursable,668.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,668.25,82.5,,534.6,percent of total billed charges,Pays at 82.5% of total Billed charges,591.3,73,,473.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,567,70,,453.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,19.19,,124.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,405,50,,324,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,668.25,
ORTHO 3.5 10MM LOCK SCREW,10081106,CDM,271,RC,,,Outpatient,,,810,810,,,,,,Other,Not Separately Reimbursable,668.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,668.25,82.5,,534.6,percent of total billed charges,Pays at 82.5% of total Billed charges,591.3,73,,473.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,567,70,,453.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,19.19,,124.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,405,50,,324,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,668.25,
ORTHO 3.5 14MM N/L SCREW,10081107,CDM,271,RC,,,Outpatient,,,810,810,,,,,,Other,Not Separately Reimbursable,668.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,668.25,82.5,,534.6,percent of total billed charges,Pays at 82.5% of total Billed charges,591.3,73,,473.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,567,70,,453.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,19.19,,124.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,405,50,,324,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,668.25,
ORTHO 3.5 LRG DRILL BIT,10081108,CDM,271,RC,,,Outpatient,,,810,810,,,,,,Other,Not Separately Reimbursable,668.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,668.25,82.5,,534.6,percent of total billed charges,Pays at 82.5% of total Billed charges,591.3,73,,473.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,567,70,,453.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,19.19,,124.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,405,50,,324,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,668.25,
ORTHO 2.4MM DRILL BIT,10081109,CDM,271,RC,,,Outpatient,,,810,810,,,,,,Other,Not Separately Reimbursable,668.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,668.25,82.5,,534.6,percent of total billed charges,Pays at 82.5% of total Billed charges,591.3,73,,473.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,567,70,,453.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,19.19,,124.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,405,50,,324,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,668.25,
ORTHO 4.0 50MM THREAD SCREW,10081110,CDM,271,RC,,,Outpatient,,,1010,1010,,,,,,Other,Not Separately Reimbursable,833.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,833.25,82.5,,666.6,percent of total billed charges,Pays at 82.5% of total Billed charges,737.3,73,,589.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,707,70,,565.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,193.82,19.19,,155.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,505,50,,404,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,193.82,833.25,
ORTHO 1.4MM GUIDE WIRE,10081111,CDM,271,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
ORTHO 2.7MM DRILL BIT,10081112,CDM,271,RC,,,Outpatient,,,810,810,,,,,,Other,Not Separately Reimbursable,668.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,668.25,82.5,,534.6,percent of total billed charges,Pays at 82.5% of total Billed charges,591.3,73,,473.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,567,70,,453.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,19.19,,124.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,405,50,,324,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,668.25,
WAND 90 DEG ARTHORSCOPY,10081113,CDM,271,RC,,,Outpatient,,,690,690,,,,,,Other,Not Separately Reimbursable,569.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,569.25,82.5,,455.4,percent of total billed charges,Pays at 82.5% of total Billed charges,503.7,73,,402.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,483,70,,386.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.41,19.19,,105.928,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,345,50,,276,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.41,569.25,
ARTHORSCOPY SHAVERS ANGLED,10081114,CDM,271,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
ARTHORSCOPY HOODLESS BUR,10081115,CDM,271,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
ARTHORSCOPY SMALL JOINT SHAVER 2.5,10081116,CDM,271,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
ARTHORSCOPY SMALL JOINT SHAVER 3.5MM,10081117,CDM,271,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
ARTHREX BIO-COMP-SITE 2.9X15.5MM,10081118,CDM,271,RC,,,Outpatient,,,950,950,,,,,,Other,Not Separately Reimbursable,783.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,783.75,82.5,,627,percent of total billed charges,Pays at 82.5% of total Billed charges,693.5,73,,554.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,665,70,,532,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182.31,19.19,,145.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,475,50,,380,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182.31,783.75,
ARTHREX DISP KIT FOR 2.9MM PUSHLOC,10081119,CDM,271,RC,,,Outpatient,,,710,710,,,,,,Other,Not Separately Reimbursable,585.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,585.75,82.5,,468.6,percent of total billed charges,Pays at 82.5% of total Billed charges,518.3,73,,414.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,497,70,,397.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,136.25,19.19,,109,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,355,50,,284,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,136.25,585.75,
ARTHREX 90 DEG CURVE STRAIT QUICKPASS LA,10081120,CDM,271,RC,,,Outpatient,,,650,650,,,,,,Other,Not Separately Reimbursable,536.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,536.25,82.5,,429,percent of total billed charges,Pays at 82.5% of total Billed charges,474.5,73,,379.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,455,70,,364,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124.74,19.19,,99.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,325,50,,260,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124.74,536.25,
ARTHREX CANNULA 7MM ID X 7CM VTRIPLEDAM,10081121,CDM,271,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
ARTHREX TIGERLINK SUTURE,10081122,CDM,271,RC,,,Outpatient,,,320,320,,,,,,Other,Not Separately Reimbursable,264,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,264,82.5,,211.2,percent of total billed charges,Pays at 82.5% of total Billed charges,233.6,73,,186.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,224,70,,179.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.41,19.19,,49.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,160,50,,128,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.41,264,
ARTHREX SUTURE TAPE 1.3MM W NEEDLE WHITE,10081123,CDM,271,RC,,,Outpatient,,,210,210,,,,,,Other,Not Separately Reimbursable,173.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,173.25,82.5,,138.6,percent of total billed charges,Pays at 82.5% of total Billed charges,153.3,73,,122.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,70,,117.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,19.19,,32.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,50,,84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,173.25,
CAST SHOES X-SM(PED),10081124,CDM,271,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
CAST SHOE SMALL,10081125,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CAST SHOE MEDIUM,10081126,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CAST SHOE LARGE,10081127,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CAST SHOE XLG,10081128,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ORTHO ROOI-C LORDTIC IMPLANT,10081129,CDM,271,RC,,,Outpatient,,,4260,4260,,,,,,Other,Not Separately Reimbursable,3514.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3514.5,82.5,,2811.6,percent of total billed charges,Pays at 82.5% of total Billed charges,3109.8,73,,2487.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2982,70,,2385.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,817.49,19.19,,653.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2130,50,,1704,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,817.49,3514.5,
ORTHO ROOI-C PLATE,10081130,CDM,271,RC,,,Outpatient,,,4260,4260,,,,,,Other,Not Separately Reimbursable,3514.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3514.5,82.5,,2811.6,percent of total billed charges,Pays at 82.5% of total Billed charges,3109.8,73,,2487.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2982,70,,2385.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,817.49,19.19,,653.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2130,50,,1704,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,817.49,3514.5,
ORTHO 1 CC DBM PUTTY,10081131,CDM,272,RC,,,Outpatient,,,490,490,,,,,,Other,Not Separately Reimbursable,404.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,404.25,82.5,,323.4,percent of total billed charges,Pays at 82.5% of total Billed charges,357.7,73,,286.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,343,70,,274.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.03,19.19,,75.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245,50,,196,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.03,404.25,
ORTHO TOTAL DISK REPLACEMENT,10081132,CDM,271,RC,,,Outpatient,,,13510,13510,,,,,,Other,Not Separately Reimbursable,11145.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11145.75,82.5,,8916.6,percent of total billed charges,Pays at 82.5% of total Billed charges,9862.3,73,,7889.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9457,70,,7565.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2592.57,19.19,,2074.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6755,50,,5404,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2592.57,11145.75,
ARTHORSCOPY WAND 50S 3.5MM ENERGY,10081133,CDM,271,RC,,,Outpatient,,,670,670,,,,,,Other,Not Separately Reimbursable,552.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,552.75,82.5,,442.2,percent of total billed charges,Pays at 82.5% of total Billed charges,489.1,73,,391.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,469,70,,375.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.57,19.19,,102.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,335,50,,268,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.57,552.75,
ORTHO 5.MM X 125 FORMULA 6-FLUTE BARREL,10081134,CDM,271,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
ORTHO 4.MM X 125 FORMULA AGGRESSIVE PLUS,10081135,CDM,271,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
DURGEN PLUS GRAFT DURAL 2INW X 2INL ULTR,10081136,CDM,271,RC,,,Outpatient,,,1550,1550,,,,,,Other,Not Separately Reimbursable,1278.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1278.75,82.5,,1023,percent of total billed charges,Pays at 82.5% of total Billed charges,1131.5,73,,905.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1085,70,,868,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,297.45,19.19,,237.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,775,50,,620,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,297.45,1278.75,
ARTHREX SCORPION-MULTIFIRE NEEDLE,10081137,CDM,271,RC,,,Outpatient,,,690,690,,,,,,Other,Not Separately Reimbursable,569.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,569.25,82.5,,455.4,percent of total billed charges,Pays at 82.5% of total Billed charges,503.7,73,,402.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,483,70,,386.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.41,19.19,,105.928,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,345,50,,276,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.41,569.25,
ARTHREX PERC INSERT KIT FOR 2.9MM P LCK,10081138,CDM,271,RC,,,Outpatient,,,890,890,,,,,,Other,Not Separately Reimbursable,734.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,734.25,82.5,,587.4,percent of total billed charges,Pays at 82.5% of total Billed charges,649.7,73,,519.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,623,70,,498.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,19.19,,136.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,445,50,,356,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,734.25,
ARTHREX SPEEDBRG IMP SYS W BIO COMP SWVL,10081139,CDM,271,RC,,,Outpatient,,,4360,4360,,,,,,Other,Not Separately Reimbursable,3597,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3597,82.5,,2877.6,percent of total billed charges,Pays at 82.5% of total Billed charges,3182.8,73,,2546.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3052,70,,2441.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,836.68,19.19,,669.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2180,50,,1744,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,836.68,3597,
ARTHREX CRESCENT QUICKPASS LASSO,10081140,CDM,271,RC,,,Outpatient,,,920,920,,,,,,Other,Not Separately Reimbursable,759,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,759,82.5,,607.2,percent of total billed charges,Pays at 82.5% of total Billed charges,671.6,73,,537.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,644,70,,515.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.55,19.19,,141.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,460,50,,368,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.55,759,
ARTHREX DISP HEAD RESTRAINTS,10081141,CDM,271,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
ORTHO MOBI-C CERVICAL DISK PROSTHEEIS,10081142,CDM,271,RC,,,Outpatient,,,13510,13510,,,,,,Other,Not Separately Reimbursable,11145.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11145.75,82.5,,8916.6,percent of total billed charges,Pays at 82.5% of total Billed charges,9862.3,73,,7889.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9457,70,,7565.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2592.57,19.19,,2074.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6755,50,,5404,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2592.57,11145.75,
ARTHREX DBL LOADER 4.75MM BIO-COMP SWVLK,10081143,CDM,271,RC,,,Outpatient,,,1790,1790,,,,,,Other,Not Separately Reimbursable,1476.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1476.75,82.5,,1181.4,percent of total billed charges,Pays at 82.5% of total Billed charges,1306.7,73,,1045.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1253,70,,1002.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,343.5,19.19,,274.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,895,50,,716,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,343.5,1476.75,
ORTHO BIO-COMP SWIVELOCK 4.75X19.1CM,10081144,CDM,271,RC,,,Outpatient,,,2020,2020,,,,,,Other,Not Separately Reimbursable,1666.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1666.5,82.5,,1333.2,percent of total billed charges,Pays at 82.5% of total Billed charges,1474.6,73,,1179.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1414,70,,1131.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,387.64,19.19,,310.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1010,50,,808,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,387.64,1666.5,
ARTHREX SUTURETAPE FIBERLONK 1.3MM,10081145,CDM,271,RC,,,Outpatient,,,122,122,,,,,,Other,Not Separately Reimbursable,100.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,100.65,82.5,,80.52,percent of total billed charges,Pays at 82.5% of total Billed charges,89.06,73,,71.248,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85.4,70,,68.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.41,19.19,,18.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61,50,,48.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.41,100.65,
ARTHREX FIBERLINK SUTURE,10081146,CDM,271,RC,,,Outpatient,,,490,490,,,,,,Other,Not Separately Reimbursable,404.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,404.25,82.5,,323.4,percent of total billed charges,Pays at 82.5% of total Billed charges,357.7,73,,286.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,343,70,,274.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.03,19.19,,75.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245,50,,196,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.03,404.25,
ARTHREX SUTR ANCH BIO-COMP P-LCK 2.9X 12,10081147,CDM,271,RC,,,Outpatient,,,1720,1720,,,,,,Other,Not Separately Reimbursable,1419,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1419,82.5,,1135.2,percent of total billed charges,Pays at 82.5% of total Billed charges,1255.6,73,,1004.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1204,70,,963.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,330.07,19.19,,264.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,860,50,,688,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,330.07,1419,
BONE GRAFT KIT INFUSE MEDIUM,10081148,CDM,271,RC,,,Outpatient,,,13260,13260,,,,,,Other,Not Separately Reimbursable,10939.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10939.5,82.5,,8751.6,percent of total billed charges,Pays at 82.5% of total Billed charges,9679.8,73,,7743.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9282,70,,7425.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2544.59,19.19,,2035.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6630,50,,5304,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2544.59,10939.5,
WAND 50 DEG ARTHORSCOPY,10081149,CDM,271,RC,,,Outpatient,,,800,800,,,,,,Other,Not Separately Reimbursable,660,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,660,82.5,,528,percent of total billed charges,Pays at 82.5% of total Billed charges,584,73,,467.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,560,70,,448,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153.52,19.19,,122.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,400,50,,320,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153.52,660,
CAST PADDING 4,10081150,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
CAST PADDING 2,10081151,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
ARTHREX DISP KIT 2.9MM SHORT PUSHLOCK,10081155,CDM,271,RC,,,Outpatient,,,1010,1010,,,,,,Other,Not Separately Reimbursable,833.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,833.25,82.5,,666.6,percent of total billed charges,Pays at 82.5% of total Billed charges,737.3,73,,589.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,707,70,,565.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,193.82,19.19,,155.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,505,50,,404,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,193.82,833.25,
ENTELLUS LATERA SYSTEM IMPLANT,10081156,CDM,271,RC,,,Outpatient,,,4990,4990,,,,,,Other,Not Separately Reimbursable,4116.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4116.75,82.5,,3293.4,percent of total billed charges,Pays at 82.5% of total Billed charges,3642.7,73,,2914.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3493,70,,2794.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,957.58,19.19,,766.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2495,50,,1996,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,957.58,4116.75,
COMPRESSION HOSE - MISC SNU/PT,10081201,CDM,272,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
CUSHION - PT MISC,10081202,CDM,272,RC,,,Outpatient,,,470,470,,,,,,Other,Not Separately Reimbursable,387.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,387.75,82.5,,310.2,percent of total billed charges,Pays at 82.5% of total Billed charges,343.1,73,,274.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329,70,,263.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,19.19,,72.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,235,50,,188,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,387.75,
CATHETER IRRIGATION TRAY,10081275,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CATHETER PLUG,10081300,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CATHETER KIT-SPECIMEN,10081302,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CATHETER KIT PEDIATRIC,10081303,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CATHETER LEG STRAP,10081350,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CATHETER PICC SECURE,10081351,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CATHETER FOLEY SECURE,10081352,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CATHETER LEG STRAP - VELCRO SNU,10081353,CDM,272,RC,L0130,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CERVICAL COLLAR (HARD),10081475,CDM,274,RC,L0120,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
CERVICAL COLLAR (FOAM) SM,10081476,CDM,274,RC,L0120,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CERVICAL COLLAR (FOAM) ME,10081477,CDM,274,RC,L0120,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CERVICAL COLLAR (FOAM) LG,10081478,CDM,274,RC,L0120,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CERVICAL COLLAR (FOAM) XLRG,10081479,CDM,274,RC,L0120,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CERVICAL COLLAR CHILD (HARD),10081481,CDM,274,RC,L0120,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CERVICAL COLLAR ADULT (HARD) PATRIOT,10081482,CDM,274,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
PACER PADS LP10,10081499,CDM,275,RC,,,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,160,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,160,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,160,
PACER PAD ADULT (ZOLL),10081500,CDM,272,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
DEFIB PADS MEDTRONIC,10081506,CDM,271,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
PRESSURE TRANSDUCER CVP ARTERIAL KIT,10081600,CDM,272,RC,,,Outpatient,,,240,240,,,,,,Other,Not Separately Reimbursable,198,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,198,82.5,,158.4,percent of total billed charges,Pays at 82.5% of total Billed charges,175.2,73,,140.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,168,70,,134.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.06,19.19,,36.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,120,50,,96,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.06,198,
ORTHO PLATE FIB LOCK RGT 10HL 158MM,10081604,CDM,271,RC,L3650,HCPCS,Outpatient,,,2520,2520,,,,,,Other,Not Separately Reimbursable,2079,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2079,82.5,,1663.2,percent of total billed charges,Pays at 82.5% of total Billed charges,1839.6,73,,1471.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1764,70,,1411.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,483.59,19.19,,386.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1260,50,,1008,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,483.59,2079,
CLAVICULAR SUPPORT SM,10081676,CDM,274,RC,L3650,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CLAVICULAR SUPPORT MED,10081677,CDM,274,RC,L3650,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CLAVICULAR SUPPORT LG,10081678,CDM,274,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
SPLINT VEL SM-LEFT,10081866,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CRUTCH ALUMINUM ALL SIZE,10081867,CDM,274,RC,,,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
WALKER ALUMINUM ALL SIZE,10081868,CDM,274,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
SUPRAFOIL 4 X4 .02,10081889,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DEFIBRILLATION - EACH USE,10081950,CDM,271,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
DELTA-LITE CAST 2 PER ROL,10081960,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CAST DELTA-LITE 3,10081970,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CAST DELTA-LITE 4,10081975,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CAST DELTA-LITE 5,10081980,CDM,271,RC,L4360,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
SPLINT ORTHOGLASS 2,10081988,CDM,274,RC,,,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
SPLINT ORTHOGLASS 4,10081989,CDM,271,RC,,,Outpatient,,,230,230,,,,,,Other,Not Separately Reimbursable,189.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,189.75,82.5,,151.8,percent of total billed charges,Pays at 82.5% of total Billed charges,167.9,73,,134.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161,70,,128.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.14,19.19,,35.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115,50,,92,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.14,189.75,
SPLINT ORTHOGLASS 5,10081990,CDM,271,RC,,,Outpatient,,,290,290,,,,,,Other,Not Separately Reimbursable,239.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,239.25,82.5,,191.4,percent of total billed charges,Pays at 82.5% of total Billed charges,211.7,73,,169.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203,70,,162.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.65,19.19,,44.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,145,50,,116,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.65,239.25,
SPLINT ORTHOGLASS 6,10081991,CDM,271,RC,,,Outpatient,,,360,360,,,,,,Other,Not Separately Reimbursable,297,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,297,82.5,,237.6,percent of total billed charges,Pays at 82.5% of total Billed charges,262.8,73,,210.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252,70,,201.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,19.19,,55.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180,50,,144,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,297,
SPLINT ORTHOGLASS 3,10081992,CDM,271,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
CAST PAD DELTA DRY 3,10082002,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
CAST PAD DELTA DRY 4,10082003,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
CAST PAD DELTA DRY 2,10082004,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
CAST PAD DELTA ROL 2,10082005,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CAST PAD DELTA ROL 3,10082006,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CAST PAD DELTA ROL 4,10082007,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SUCTION CATH-DELEE 5FR,10082200,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SUCTION CATH-BALLARD,10082201,CDM,272,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
SUCTION FRAZIER 10FR,10082202,CDM,272,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
SUCTION VALVE LOPEZ,10082203,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DRESSING - MEPILEX BORDER,10082219,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRESSING - XTRASORB HCS,10082220,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DRESSING - XTRASORB,10082221,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRESSING - EXUDERM HC 4X4,10082222,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - ELASTO DERMA GEL 4X4,10082223,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRESSING - OPTIFOAM 4X4,10082229,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRESSING - OPTIFOAM 4X4 ADHESIVE,10082230,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DRESSING - RESTON FOAM,10082231,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DRESSING - AMD FOAM (KENDALL),10082232,CDM,272,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
DRESSING - OPTIFOAM 6X5 SACRAL,10082233,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ENEMA S S BAG,10082375,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENTERAL PUMP DAILY RENT,10082378,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
ENDO 4MM,10082417,CDM,271,RC,,,Outpatient,,,780,780,,,,,,Other,Not Separately Reimbursable,643.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,643.5,82.5,,514.8,percent of total billed charges,Pays at 82.5% of total Billed charges,569.4,73,,455.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,546,70,,436.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.68,19.19,,119.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,390,50,,312,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.68,643.5,
ENDO SHEERS,10082418,CDM,272,RC,,,Outpatient,,,620,620,,,,,,Other,Not Separately Reimbursable,511.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,511.5,82.5,,409.2,percent of total billed charges,Pays at 82.5% of total Billed charges,452.6,73,,362.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,434,70,,347.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,118.98,19.19,,95.184,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,310,50,,248,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,118.98,511.5,
ANES COFLOW EXT SET,10082426,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ANES STOPCOCK,10082427,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ANES DISPENSING PIN,10082428,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SKIN CLIP 35W,10082445,CDM,272,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
ENDO KITNER,10082446,CDM,272,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
ENDO GIA 30/35 - 2.0MM GUN (MULTIFIRE),10082448,CDM,271,RC,,,Outpatient,,,790,790,,,,,,Other,Not Separately Reimbursable,651.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,651.75,82.5,,521.4,percent of total billed charges,Pays at 82.5% of total Billed charges,576.7,73,,461.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,553,70,,442.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.6,19.19,,121.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,395,50,,316,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.6,651.75,
ENDO GIA 30/35 - 2.0MM REFILL CARTRIDGE,10082449,CDM,271,RC,,,Outpatient,,,730,730,,,,,,Other,Not Separately Reimbursable,602.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,602.25,82.5,,481.8,percent of total billed charges,Pays at 82.5% of total Billed charges,532.9,73,,426.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,511,70,,408.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140.09,19.19,,112.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,365,50,,292,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140.09,602.25,
ENDO - LAPRA-TY SUTURE 33CM APPLIER,10082450,CDM,271,RC,,,Outpatient,,,2710,2710,,,,,,Other,Not Separately Reimbursable,2235.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2235.75,82.5,,1788.6,percent of total billed charges,Pays at 82.5% of total Billed charges,1978.3,73,,1582.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1897,70,,1517.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,520.05,19.19,,416.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1355,50,,1084,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,520.05,2235.75,
ENDO - LAPRA-TY SUTURE CLIPS,10082451,CDM,271,RC,,,Outpatient,,,280,280,,,,,,Other,Not Separately Reimbursable,231,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,231,82.5,,184.8,percent of total billed charges,Pays at 82.5% of total Billed charges,204.4,73,,163.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,196,70,,156.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.73,19.19,,42.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,50,,112,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.73,231,
LIGA CLIP SM,10082454,CDM,272,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
LIGA CLIP MED/LG,10082455,CDM,272,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
LIGA CLIP MED/LG (UROLOGIST),10082456,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
LIGA CLIP LG (UROLOGIST),10082457,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ROTH RETRIEVAL NET,10082495,CDM,272,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
"POLYP SNARE, ROTATABLE",10082496,CDM,272,RC,,,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,123.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,123.75,82.5,,99,percent of total billed charges,Pays at 82.5% of total Billed charges,109.5,73,,87.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,70,,84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,19.19,,23.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75,50,,60,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,123.75,
NEEDLE INTRAOSSEOUS 18GA,10082497,CDM,272,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
NEEDLE INTRAOSSEOUS 15GA,10082498,CDM,272,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
NEEDLE I/O ADULT SET,10082499,CDM,272,RC,,,Outpatient,,,580,580,,,,,,Other,Not Separately Reimbursable,478.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,478.5,82.5,,382.8,percent of total billed charges,Pays at 82.5% of total Billed charges,423.4,73,,338.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,406,70,,324.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.3,19.19,,89.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,290,50,,232,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.3,478.5,
NEEDLE I/O PEDI SET,10082500,CDM,272,RC,,,Outpatient,,,580,580,,,,,,Other,Not Separately Reimbursable,478.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,478.5,82.5,,382.8,percent of total billed charges,Pays at 82.5% of total Billed charges,423.4,73,,338.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,406,70,,324.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.3,19.19,,89.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,290,50,,232,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.3,478.5,
NEEDLE I/O 45MM (XLG) SET,10082501,CDM,272,RC,,,Outpatient,,,550,550,,,,,,Other,Not Separately Reimbursable,453.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,453.75,82.5,,363,percent of total billed charges,Pays at 82.5% of total Billed charges,401.5,73,,321.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,385,70,,308,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.55,19.19,,84.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,275,50,,220,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.55,453.75,
GYN - NEEDLE 120MM PNEUMO,10082503,CDM,272,RC,,,Outpatient,,,430,430,,,,,,Other,Not Separately Reimbursable,354.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,354.75,82.5,,283.8,percent of total billed charges,Pays at 82.5% of total Billed charges,313.9,73,,251.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,301,70,,240.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.52,19.19,,66.016,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,215,50,,172,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.52,354.75,
GYN - PELVILACE URETHRAL SUPPORT W/HOOK,10082504,CDM,272,RC,,,Outpatient,,,2930,2930,,,,,,Other,Not Separately Reimbursable,2417.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2417.25,82.5,,1933.8,percent of total billed charges,Pays at 82.5% of total Billed charges,2138.9,73,,1711.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2051,70,,1640.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,562.27,19.19,,449.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1465,50,,1172,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,562.27,2417.25,
GYN - ZUMI UTERINE 4.5MM INJECTOR,10082505,CDM,272,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
EYE PATCH - EACH,10082525,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
STERI STRIP - 1/2,10082550,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
STERI STRIP 1,10082551,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
STERI STRIP 1/4,10082552,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SEPARATOR SYSTEM,10082556,CDM,272,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
ENDOTRACH TUBE 2.5,10082574,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENDOTRACH TUBE 3.0,10082575,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENDOTRACH TUBE 3.5,10082576,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENDOTRACH TUBE 4.0,10082577,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENDOTRACH TUBE 4.5,10082578,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENDOTRACH TUBE 5.0,10082579,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENDOTRACH TUBE 5.5,10082580,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENDOTRACH TUBE 6.0,10082581,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENDOTRACH TUBE 6.5,10082582,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENDOTRACH TUBE 7.0,10082583,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENDOTRACH TUBE 7.5,10082584,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENDOTRACH TUBE 8.0,10082585,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENDOTRACH TUBE 8.5,10082586,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENDOTRACH BOUGIE (INTRODUCER),10082587,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ENDOTRACH TUBE 9.0,10082589,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
TRACHEOSTOMY - SHILEY 10,10082591,CDM,272,RC,,,Outpatient,,,210,210,,,,,,Other,Not Separately Reimbursable,173.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,173.25,82.5,,138.6,percent of total billed charges,Pays at 82.5% of total Billed charges,153.3,73,,122.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,70,,117.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,19.19,,32.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,50,,84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,173.25,
ENDOTRACH RAE PRE - FORM CUFFED 3.5,10082592,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ENDOTRACH RAE PRE - FORM CUFFED 4.0,10082593,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ENDOTRACH RAE PRE - FORM CUFFED 4.5,10082594,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ENDOTRACH RAE PRE - FORM CUFFED 5.0,10082595,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ENDOTRACH RAE PRE - FORM CUFFED 5.5,10082596,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ENDOTRACH RAE PRE - FORM CUFFED 6.0,10082597,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
E R SUTURE TRAY,10082600,CDM,272,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
ESOPHAGEAL STETHOSCOPES,10082625,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SURGICEL HEMOSTAT 2X3,10082686,CDM,272,RC,,,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
DERMABOND (SURGISEAL),10082689,CDM,272,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
DERAPREP SOLUTION W APPLICATOR,10082690,CDM,272,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
ORTHO PRONEVIEW CHUSHION INSERT LARGE,10082691,CDM,274,RC,,,Outpatient,,,135,135,,,,,,Other,Not Separately Reimbursable,111.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,111.38,82.5,,89.104,percent of total billed charges,Pays at 82.5% of total Billed charges,98.55,73,,78.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.5,70,,75.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.91,19.19,,20.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.5,50,,54,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.91,111.38,
BIOPSY FORCEP COLD,10082758,CDM,272,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
BIOPSY FORCEP COLD W/SPIKE,10082759,CDM,272,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
BIOPSY PUNCH 3 MM,10082760,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
BIOPSY PUNCH 2 MM,10082761,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
BIOPSY PUNCH 4 MM,10082762,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CAUTERY LOW TEMP,10082765,CDM,272,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
GRASPER FOOD IMPACTION,10082769,CDM,272,RC,,,Outpatient,,,470,470,,,,,,Other,Not Separately Reimbursable,387.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,387.75,82.5,,310.2,percent of total billed charges,Pays at 82.5% of total Billed charges,343.1,73,,274.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329,70,,263.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,19.19,,72.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,235,50,,188,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,387.75,
GRASPING DEVICE RAPTOR,10082770,CDM,272,RC,,,Outpatient,,,530,530,,,,,,Other,Not Separately Reimbursable,437.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,437.25,82.5,,349.8,percent of total billed charges,Pays at 82.5% of total Billed charges,386.9,73,,309.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371,70,,296.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,19.19,,81.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,265,50,,212,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,437.25,
ESOPHAGEAL OVERTUBE (GUARDUS),10082771,CDM,272,RC,,,Outpatient,,,790,790,,,,,,Other,Not Separately Reimbursable,651.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,651.75,82.5,,521.4,percent of total billed charges,Pays at 82.5% of total Billed charges,576.7,73,,461.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,553,70,,442.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.6,19.19,,121.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,395,50,,316,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.6,651.75,
FOLEY CATHETER 8FR 3CC,10082802,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
FOLEY CATHETER 10FR 3CC,10082803,CDM,272,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
FOLEY CATHETER 12FR 10CC,10082804,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FOLEY CATHETER 14FR 10CC,10082805,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FOLEY CATHETER 16FR 10ML,10082806,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FOLEY CATHETER 18FR 5CC,10082807,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FOLEY CATHETER 20FR 10CC,10082808,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FOLEY CATHETER 24FR 5CC,10082810,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FOLEY CATHETER 26FR 5CC,10082811,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
FOLEY CATHETER 28FR 5CC,10082812,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
FOLEY CATHETER 16FR 30CC,10082814,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FOLEY CATHETER 18FR 30CC,10082816,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FOLEY CATHETER 20FR 30CC,10082817,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FOLEY CATHETER 22FR 30CC,10082819,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FOLEY CATHETER 24FR 30CC,10082821,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FOLEY CATHETER 26FR 30CC,10082823,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
FOLEY CATH 24FR 30CC 3WAY,10082826,CDM,272,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
FOLEY CATHETER 30FR 5CC,10082828,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
FOLEY CATHETER 30FR 30CC,10082829,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ROBNEL CATH 12FR,10082830,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FOLEY CATHETER 22FR 5CC,10082831,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FOLEY CATH 18FR 30/10CC 3WAY,10082833,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CATHETER FOGARTY 3FR,10082835,CDM,272,RC,,,Outpatient,,,360,360,,,,,,Other,Not Separately Reimbursable,297,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,297,82.5,,237.6,percent of total billed charges,Pays at 82.5% of total Billed charges,262.8,73,,210.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252,70,,201.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,19.19,,55.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180,50,,144,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,297,
CATHETER FOGARTY 2FR,10082836,CDM,272,RC,,,Outpatient,,,550,550,,,,,,Other,Not Separately Reimbursable,453.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,453.75,82.5,,363,percent of total billed charges,Pays at 82.5% of total Billed charges,401.5,73,,321.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,385,70,,308,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.55,19.19,,84.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,275,50,,220,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.55,453.75,
CATHETER FOGARTY 4FR,10082837,CDM,272,RC,,,Outpatient,,,360,360,,,,,,Other,Not Separately Reimbursable,297,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,297,82.5,,237.6,percent of total billed charges,Pays at 82.5% of total Billed charges,262.8,73,,210.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252,70,,201.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,19.19,,55.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180,50,,144,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,297,
FOLEY CATHETER 14/5 NON LATEX,10082841,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
FOLEY CATHETER 16/5 NON LATEX,10082842,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ENEMA - FLEETS (GREEN),10082850,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENEMA - FLEETS PEDIATRIC,10082851,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENEMA - FLEETS (OIL),10082852,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FOLEY CATHETER 16FR 10ML - SILICONE N/L,10082855,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
FOLEY CATHETER 20FR 10ML - SILICONE N/L,10082856,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
FINGER SPLINT 1 FOAM,10082876,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FINGER SPLINT 3/4 FOAM,10082879,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
AMBU BAG DISP ADULT,10082890,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
AMBU-DISP CHILD,10082891,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
AMBU-DISP INFANT,10082892,CDM,271,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
AMBU BAG DISP ADULT W/PEEP VALVE,10082893,CDM,271,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
SPONGES 2X2 STERILE PACK,10082898,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SPONGE 2X2 STERILE EACH,10082899,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SPONGES 4X4 STERILE - BOX,10082900,CDM,270,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
SPONGES 4X4 - STERILE EACH,10082901,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SPONGES 4X4 STERILE 10-PACK,10082903,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DERMATONE BLADE,10082928,CDM,272,RC,L1906,HCPCS,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
SCROTAL SUPPORT LG,10082999,CDM,274,RC,L1906,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
SCROTAL SUPPORT MD,10083000,CDM,274,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
TRI-LUMEN TRAY PEDIATRIC,10083013,CDM,272,RC,,,Outpatient,,,260,260,,,,,,Other,Not Separately Reimbursable,214.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,214.5,82.5,,171.6,percent of total billed charges,Pays at 82.5% of total Billed charges,189.8,73,,151.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182,70,,145.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,19.19,,39.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,130,50,,104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,214.5,
MULTI FLO ADAPTER (DESERET),10083081,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
PODIATRY - 2.5MM SUTURE ANCHOR,10083212,CDM,272,RC,,,Outpatient,,,1150,1150,,,,,,Other,Not Separately Reimbursable,948.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,948.75,82.5,,759,percent of total billed charges,Pays at 82.5% of total Billed charges,839.5,73,,671.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,805,70,,644,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,220.69,19.19,,176.552,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,575,50,,460,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,220.69,948.75,
PODIATRY - 2.8MM SHOULDER KIT,10083213,CDM,272,RC,,,Outpatient,,,850,850,,,,,,Other,Not Separately Reimbursable,701.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,701.25,82.5,,561,percent of total billed charges,Pays at 82.5% of total Billed charges,620.5,73,,496.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595,70,,476,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.12,19.19,,130.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,425,50,,340,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.12,701.25,
HEEL AND ELBOW PROTECTOR,10083275,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
SHODDED BOVIE BLADE,10083554,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
I V CATH 18GA DUAL ARROW,10083598,CDM,272,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
I V CATH 20GA DUAL,10083599,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
I V CATH 22GA,10083605,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
NEEDLE HUBER 20 3/4,10083606,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
I V CATH 10GA,10083607,CDM,272,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
TWIN-CATH 18GA,10083608,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
NEEDLE 14G BIOPSY,10083609,CDM,272,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
I V CATH 12GA,10083611,CDM,272,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
PICC LINE 2FR TRAY,10083613,CDM,272,RC,,,Outpatient,,,420,420,,,,,,Other,Not Separately Reimbursable,346.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,346.5,82.5,,277.2,percent of total billed charges,Pays at 82.5% of total Billed charges,306.6,73,,245.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,294,70,,235.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.6,19.19,,64.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,210,50,,168,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.6,346.5,
PICC INTRO 18GA,10083614,CDM,272,RC,,,Outpatient,,,170,170,,,,,,Other,Not Separately Reimbursable,140.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,140.25,82.5,,112.2,percent of total billed charges,Pays at 82.5% of total Billed charges,124.1,73,,99.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,119,70,,95.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.62,19.19,,26.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85,50,,68,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.62,140.25,
PICC LINE 3FR TRAY,10083615,CDM,272,RC,,,Outpatient,,,180,180,,,,,,Other,Not Separately Reimbursable,148.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,148.5,82.5,,118.8,percent of total billed charges,Pays at 82.5% of total Billed charges,131.4,73,,105.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126,70,,100.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,19.19,,27.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90,50,,72,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,148.5,
PICC LINE 4FR KIT,10083616,CDM,272,RC,,,Outpatient,,,430,430,,,,,,Other,Not Separately Reimbursable,354.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,354.75,82.5,,283.8,percent of total billed charges,Pays at 82.5% of total Billed charges,313.9,73,,251.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,301,70,,240.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.52,19.19,,66.016,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,215,50,,172,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.52,354.75,
PICC INTRO 20GA,10083617,CDM,272,RC,,,Outpatient,,,170,170,,,,,,Other,Not Separately Reimbursable,140.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,140.25,82.5,,112.2,percent of total billed charges,Pays at 82.5% of total Billed charges,124.1,73,,99.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,119,70,,95.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.62,19.19,,26.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85,50,,68,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.62,140.25,
PICC LINE KIT W/GUIDEWIRE 3FR,10083618,CDM,272,RC,,,Outpatient,,,740,740,,,,,,Other,Not Separately Reimbursable,610.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,610.5,82.5,,488.4,percent of total billed charges,Pays at 82.5% of total Billed charges,540.2,73,,432.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,518,70,,414.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,142.01,19.19,,113.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,370,50,,296,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,142.01,610.5,
SUCTION COAGULATOR (DISP) FOOT,10083620,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
SUCTION COAGULATOR HANDHELD,10083621,CDM,272,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
GYN - TUBING SET HYSTEROMAT,10083631,CDM,272,RC,,,Outpatient,,,400,400,,,,,,Other,Not Separately Reimbursable,330,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,330,82.5,,264,percent of total billed charges,Pays at 82.5% of total Billed charges,292,73,,233.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280,70,,224,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.76,19.19,,61.408,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,200,50,,160,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.76,330,
GYN - GENESYS PROCEDURE SET,10083632,CDM,272,RC,,,Outpatient,,,3510,3510,,,,,,Other,Not Separately Reimbursable,2895.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2895.75,82.5,,2316.6,percent of total billed charges,Pays at 82.5% of total Billed charges,2562.3,73,,2049.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2457,70,,1965.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,673.57,19.19,,538.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1755,50,,1404,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,673.57,2895.75,
NEEDLE CARR LOCKE INJECT,10083645,CDM,272,RC,L1906,HCPCS,Outpatient,,,260,260,,,,,,Other,Not Separately Reimbursable,214.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,214.5,82.5,,171.6,percent of total billed charges,Pays at 82.5% of total Billed charges,189.8,73,,151.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182,70,,145.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,19.19,,39.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,130,50,,104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,214.5,
SPLINT AIR ANKLE UNIVERSAL,10083660,CDM,274,RC,L1906,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
SPLINT ANKLE FOOT ORTHOSIS PT,10083661,CDM,274,RC,L1906,HCPCS,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
SPLINT WRIST BEND EASE LEFT,10083662,CDM,274,RC,,,Outpatient,,,230,230,,,,,,Other,Not Separately Reimbursable,189.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,189.75,82.5,,151.8,percent of total billed charges,Pays at 82.5% of total Billed charges,167.9,73,,134.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161,70,,128.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.14,19.19,,35.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115,50,,92,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.14,189.75,
NASAL EPISTAXIS ANT 4.5CM,10083665,CDM,272,RC,,,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,123.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,123.75,82.5,,99,percent of total billed charges,Pays at 82.5% of total Billed charges,109.5,73,,87.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,70,,84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,19.19,,23.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75,50,,60,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,123.75,
NASAL EPISTAXIS ANT 5.5CM,10083666,CDM,272,RC,,,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,123.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,123.75,82.5,,99,percent of total billed charges,Pays at 82.5% of total Billed charges,109.5,73,,87.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,70,,84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,19.19,,23.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75,50,,60,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,123.75,
NASAL EPISTAXIS ANT 5.5CM AIRWAY,10083667,CDM,272,RC,,,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
NASAL EPISTAXIS POST 7.5,10083668,CDM,271,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
CAST PADDING 3,10083669,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
MESH PROLENE 6X6,10083728,CDM,278,RC,,,Outpatient,,,750,750,,,,,,Other,Not Separately Reimbursable,750,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,750,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,547.5,73,,438,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,525,70,,420,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.93,19.19,,115.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,375,50,,300,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.93,750,
MESH PROLENE 3X6,10083729,CDM,278,RC,,,Outpatient,,,830,830,,,,,,Other,Not Separately Reimbursable,830,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,830,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,605.9,73,,484.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,581,70,,464.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,159.28,19.19,,127.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,415,50,,332,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,159.28,830,
MESH ULTRAPRO 15X15CM,10083730,CDM,278,RC,,,Outpatient,,,1050,1050,,,,,,Other,Not Separately Reimbursable,1050,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1050,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,766.5,73,,613.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,735,70,,588,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,201.5,19.19,,161.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,525,50,,420,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,201.5,1050,
NASAL EPISTAXIS ANT R/P 5.5CM,10083769,CDM,272,RC,,,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,123.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,123.75,82.5,,99,percent of total billed charges,Pays at 82.5% of total Billed charges,109.5,73,,87.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,70,,84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,19.19,,23.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75,50,,60,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,123.75,
NASAL EPISTAXIS ANT/POST BI LAT 7.5,10083770,CDM,271,RC,,,Outpatient,,,180,180,,,,,,Other,Not Separately Reimbursable,148.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,148.5,82.5,,118.8,percent of total billed charges,Pays at 82.5% of total Billed charges,131.4,73,,105.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126,70,,100.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,19.19,,27.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90,50,,72,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,148.5,
NASAL EPISTAXIS 7.5 INF W/AIRWAY,10083771,CDM,271,RC,,,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
EAR WICK,10083777,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
ENT - DRESSING SINUSTENT,10083807,CDM,272,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
ENT - PACKING POPE FLEX,10083809,CDM,272,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
TRAY LACERATION DISPOSABLE,10083829,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CAST PADDING 6,10083836,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
JACKSON PRATT RESERVIOR BULB,10083860,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
RESTRAINT POSEY VEST MEDIUM,10083867,CDM,270,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
RESTRAINT POSEY VEST LARGE,10083868,CDM,270,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
RESTRAINT POSEY VEST XLG,10083869,CDM,270,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
JACKSON PRATT DRAIN 7 MM,10083870,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
JACKSON PRATT DRAIN 15MM,10083871,CDM,272,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
SURGICAL TLS DRAIN,10083872,CDM,272,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
JACKSON PRATT DRAIN 10 MM,10083873,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
BANDAGE KLING 2,10083925,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
BANDAGE KLING 3,10083926,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
BANDAGE KLING 4,10083927,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
BANDAGE KLING 6,10083928,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
BANDAGE KERLIX -BULKEE,10083929,CDM,270,RC,L1830,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
KNEE IMMOBILZER SM,10083930,CDM,274,RC,L1830,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
KNEE IMMOBILZER MED,10083931,CDM,274,RC,L1830,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
KNEE IMMOBILZER LG,10083932,CDM,274,RC,L1830,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
KNEE IMMOBILZER XLG,10083933,CDM,274,RC,L1830,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
KNEE IMMOBILZER UNIVERSAL,10083934,CDM,274,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
BALLOON 6X20MM XPRESS LOW PROFILE,10083955,CDM,272,RC,,,Outpatient,,,3780,3780,,,,,,Other,Not Separately Reimbursable,3118.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3118.5,82.5,,2494.8,percent of total billed charges,Pays at 82.5% of total Billed charges,2759.4,73,,2207.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2646,70,,2116.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,725.38,19.19,,580.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1890,50,,1512,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,725.38,3118.5,
BALLOON DILATOR 18,10083958,CDM,272,RC,,,Outpatient,,,310,310,,,,,,Other,Not Separately Reimbursable,255.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,255.75,82.5,,204.6,percent of total billed charges,Pays at 82.5% of total Billed charges,226.3,73,,181.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,217,70,,173.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,19.19,,47.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155,50,,124,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,255.75,
BALLOON DILATOR 12,10083959,CDM,272,RC,,,Outpatient,,,390,390,,,,,,Other,Not Separately Reimbursable,321.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,321.75,82.5,,257.4,percent of total billed charges,Pays at 82.5% of total Billed charges,284.7,73,,227.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,273,70,,218.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.84,19.19,,59.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,195,50,,156,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.84,321.75,
BALLOON DILATOR 14,10083960,CDM,272,RC,,,Outpatient,,,310,310,,,,,,Other,Not Separately Reimbursable,255.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,255.75,82.5,,204.6,percent of total billed charges,Pays at 82.5% of total Billed charges,226.3,73,,181.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,217,70,,173.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,19.19,,47.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155,50,,124,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,255.75,
BALLOON DILATOR 16,10083961,CDM,272,RC,,,Outpatient,,,310,310,,,,,,Other,Not Separately Reimbursable,255.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,255.75,82.5,,204.6,percent of total billed charges,Pays at 82.5% of total Billed charges,226.3,73,,181.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,217,70,,173.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,19.19,,47.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155,50,,124,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,255.75,
BALLOON INFLATOR ( USE X 3 ),10083962,CDM,272,RC,,,Outpatient,,,450,450,,,,,,Other,Not Separately Reimbursable,371.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,371.25,82.5,,297,percent of total billed charges,Pays at 82.5% of total Billed charges,328.5,73,,262.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,315,70,,252,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.36,19.19,,69.088,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,225,50,,180,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.36,371.25,
BALLOON INFLATOR BULB USSC,10083963,CDM,272,RC,,,Outpatient,,,890,890,,,,,,Other,Not Separately Reimbursable,734.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,734.25,82.5,,587.4,percent of total billed charges,Pays at 82.5% of total Billed charges,649.7,73,,519.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,623,70,,498.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,19.19,,136.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,445,50,,356,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,734.25,
BALLOON DILATOR CRE FIXED WIRE 18-19-20,10083965,CDM,272,RC,,,Outpatient,,,760,760,,,,,,Other,Not Separately Reimbursable,627,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,627,82.5,,501.6,percent of total billed charges,Pays at 82.5% of total Billed charges,554.8,73,,443.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,532,70,,425.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,145.84,19.19,,116.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,380,50,,304,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,145.84,627,
BALLOON DILATOR GAUGE SINGLE USE,10083966,CDM,272,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
BALLOON DILATOR 20,10083967,CDM,272,RC,,,Outpatient,,,310,310,,,,,,Other,Not Separately Reimbursable,255.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,255.75,82.5,,204.6,percent of total billed charges,Pays at 82.5% of total Billed charges,226.3,73,,181.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,217,70,,173.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,19.19,,47.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155,50,,124,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,255.75,
LMA MASK #4,10083968,CDM,272,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
WECK CELLS,10083969,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
LMA MASK #5,10083970,CDM,272,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
LMA MASK #3,10083971,CDM,272,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
LMA MASK # 2.5,10083972,CDM,272,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
LMA MASK 1,10083973,CDM,272,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
LMA MASK 1.5,10083974,CDM,272,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
LMA MASK 2,10083976,CDM,272,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
LMA MASK AIRQ 3.5,10083979,CDM,272,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
LMA MASK AIRQ 4.5,10083980,CDM,272,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
LMA MASK AIRQ 2.5,10083981,CDM,272,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
LMA MASK AIRQ 2.0,10083982,CDM,272,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
LMA MASK UNIQUE SILICONE SIZE 5,10083987,CDM,272,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
ORTHO 2.3 ICONIX DISP DRILL,10084121,CDM,271,RC,L0625,HCPCS,Outpatient,,,920,920,,,,,,Other,Not Separately Reimbursable,759,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,759,82.5,,607.2,percent of total billed charges,Pays at 82.5% of total Billed charges,671.6,73,,537.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,644,70,,515.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.55,19.19,,141.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,460,50,,368,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.55,759,
LUMBOSACRAL SUPPORT SM,10084175,CDM,274,RC,L0625,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
LUMBOSACRAL SUPPORT MED,10084176,CDM,274,RC,L0625,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
LUMBOSACRAL SUPPORT LG,10084177,CDM,274,RC,L0625,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
LUMBOSACRAL SUPPORT XLG,10084178,CDM,274,RC,L0625,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
LUMBOSACRAL SUPPORT XXLG,10084179,CDM,274,RC,L0455,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
TLSO LUMBAR BRACE,10084180,CDM,274,RC,L0625,HCPCS,Outpatient,,,1960,1960,,,,,,Other,Not Separately Reimbursable,1617,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1617,82.5,,1293.6,percent of total billed charges,Pays at 82.5% of total Billed charges,1430.8,73,,1144.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1372,70,,1097.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,376.12,19.19,,300.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,980,50,,784,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,376.12,1617,
LSO LUMBAR BRACE,10084181,CDM,274,RC,,,Outpatient,,,910,910,,,,,,Other,Not Separately Reimbursable,750.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,750.75,82.5,,600.6,percent of total billed charges,Pays at 82.5% of total Billed charges,664.3,73,,531.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,637,70,,509.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.63,19.19,,139.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,455,50,,364,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.63,750.75,
ORTHO MICRO ASNIS TRAY,10084212,CDM,271,RC,,,Outpatient,,,1010,1010,,,,,,Other,Not Separately Reimbursable,833.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,833.25,82.5,,666.6,percent of total billed charges,Pays at 82.5% of total Billed charges,737.3,73,,589.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,707,70,,565.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,193.82,19.19,,155.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,505,50,,404,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,193.82,833.25,
NEEDLE 14 3.25 DECOMPRESSION,10084258,CDM,272,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
NEEDLE HUBER 19M 1,10084259,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
NEEDLE HUBER 22 3/4 (CHH),10084260,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
NEEDLE HUBER 20 1.5 (ER),10084261,CDM,272,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
NEEDLE HUBER 22 .5 (PEDI),10084265,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
NEEDLE HUBER 19M 3/4,10084266,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
SKIN GRAFT MESHER CARRIER,10084298,CDM,278,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,60,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,60,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,60,
I V CATH INSYTE N PEDIATRIC,10084322,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
COMBITUBE,10084372,CDM,271,RC,,,Outpatient,,,250,250,,,,,,Other,Not Separately Reimbursable,206.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,206.25,82.5,,165,percent of total billed charges,Pays at 82.5% of total Billed charges,182.5,73,,146,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,70,,140,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,19.19,,38.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125,50,,100,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,206.25,
ORTHO - 12MM 2.3 N/L SCREW,10084555,CDM,272,RC,,,Outpatient,,,530,530,,,,,,Other,Not Separately Reimbursable,437.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,437.25,82.5,,349.8,percent of total billed charges,Pays at 82.5% of total Billed charges,386.9,73,,309.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371,70,,296.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,19.19,,81.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,265,50,,212,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,437.25,
ORTHO - 13MM 2.3 N/L SCREW,10084556,CDM,272,RC,,,Outpatient,,,550,550,,,,,,Other,Not Separately Reimbursable,453.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,453.75,82.5,,363,percent of total billed charges,Pays at 82.5% of total Billed charges,401.5,73,,321.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,385,70,,308,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.55,19.19,,84.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,275,50,,220,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.55,453.75,
ORTHO - 14MM 2.3 N/L SCREW,10084557,CDM,272,RC,,,Outpatient,,,530,530,,,,,,Other,Not Separately Reimbursable,437.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,437.25,82.5,,349.8,percent of total billed charges,Pays at 82.5% of total Billed charges,386.9,73,,309.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371,70,,296.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,19.19,,81.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,265,50,,212,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,437.25,
DRESSING - XEROFORM 1X8,10084558,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ORTHO - 13MM 2.3 LOCK SCREW,10084560,CDM,272,RC,,,Outpatient,,,530,530,,,,,,Other,Not Separately Reimbursable,437.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,437.25,82.5,,349.8,percent of total billed charges,Pays at 82.5% of total Billed charges,386.9,73,,309.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371,70,,296.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,19.19,,81.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,265,50,,212,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,437.25,
ORTHO - 2.3MM LOCKING PLATE,10084561,CDM,272,RC,,,Outpatient,,,2030,2030,,,,,,Other,Not Separately Reimbursable,1674.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1674.75,82.5,,1339.8,percent of total billed charges,Pays at 82.5% of total Billed charges,1481.9,73,,1185.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1421,70,,1136.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,389.56,19.19,,311.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1015,50,,812,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,389.56,1674.75,
ORTHO - 1.9 DRILL BIT,10084562,CDM,272,RC,,,Outpatient,,,670,670,,,,,,Other,Not Separately Reimbursable,552.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,552.75,82.5,,442.2,percent of total billed charges,Pays at 82.5% of total Billed charges,489.1,73,,391.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,469,70,,375.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.57,19.19,,102.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,335,50,,268,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.57,552.75,
EYE IRRIGATOR - MORGAN LENS,10084625,CDM,271,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
ENDO HERNIA,10084628,CDM,271,RC,,,Outpatient,,,270,270,,,,,,Other,Not Separately Reimbursable,222.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,222.75,82.5,,178.2,percent of total billed charges,Pays at 82.5% of total Billed charges,197.1,73,,157.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,189,70,,151.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.81,19.19,,41.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,135,50,,108,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.81,222.75,
NASAL EXPISTAXIS ANT/POST 7.5CM,10084711,CDM,272,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
BIOPSY NEEDLE #2N2702,10084750,CDM,272,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
PODIATRY - 12MM EVANS WEDGE,10084841,CDM,272,RC,,,Outpatient,,,6630,6630,,,,,,Other,Not Separately Reimbursable,5469.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5469.75,82.5,,4375.8,percent of total billed charges,Pays at 82.5% of total Billed charges,4839.9,73,,3871.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4641,70,,3712.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1272.3,19.19,,1017.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3315,50,,2652,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1272.3,5469.75,
OP CHOLANGIOGRAM CATH 5.5,10084874,CDM,272,RC,,,Outpatient,,,210,210,,,,,,Other,Not Separately Reimbursable,173.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,173.25,82.5,,138.6,percent of total billed charges,Pays at 82.5% of total Billed charges,153.3,73,,122.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,70,,117.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,19.19,,32.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,50,,84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,173.25,
OP CHOLANGIOGRAM CATH 7.5,10084875,CDM,272,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
OP CHOLANGIOGRAM CATH 6.5,10084876,CDM,272,RC,,,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,123.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,123.75,82.5,,99,percent of total billed charges,Pays at 82.5% of total Billed charges,109.5,73,,87.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,70,,84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,19.19,,23.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75,50,,60,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,123.75,
PODIATRY - 10MM EVANS WEDGE,10084878,CDM,272,RC,,,Outpatient,,,4950,4950,,,,,,Other,Not Separately Reimbursable,4083.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4083.75,82.5,,3267,percent of total billed charges,Pays at 82.5% of total Billed charges,3613.5,73,,2890.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3465,70,,2772,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,949.91,19.19,,759.928,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2475,50,,1980,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,949.91,4083.75,
PODIATRY - 5.5 ZIP ANCHOR,10084879,CDM,272,RC,,,Outpatient,,,1085.49,1085.49,,,,,,Other,Not Separately Reimbursable,895.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,895.53,82.5,,716.424,percent of total billed charges,Pays at 82.5% of total Billed charges,792.41,73,,633.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,759.84,70,,607.872,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,208.31,19.19,,166.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,542.75,50,,434.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,208.31,895.53,
PODIATRY - 1.2 K WIRE,10084880,CDM,272,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
PODIATRY - 3.2 COUNTER SCREW,10084881,CDM,272,RC,,,Outpatient,,,980,980,,,,,,Other,Not Separately Reimbursable,808.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,808.5,82.5,,646.8,percent of total billed charges,Pays at 82.5% of total Billed charges,715.4,73,,572.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,686,70,,548.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,188.06,19.19,,150.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,490,50,,392,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,188.06,808.5,
PODIATRY - 2.1 CANNULATED DRILL,10084882,CDM,272,RC,,,Outpatient,,,980,980,,,,,,Other,Not Separately Reimbursable,808.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,808.5,82.5,,646.8,percent of total billed charges,Pays at 82.5% of total Billed charges,715.4,73,,572.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,686,70,,548.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,188.06,19.19,,150.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,490,50,,392,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,188.06,808.5,
PODIATRY - 22MM 3.0 ASNIS SCREW,10084883,CDM,272,RC,,,Outpatient,,,840,840,,,,,,Other,Not Separately Reimbursable,693,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,693,82.5,,554.4,percent of total billed charges,Pays at 82.5% of total Billed charges,613.2,73,,490.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,588,70,,470.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,19.19,,128.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,420,50,,336,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,693,
PODIATRY - 20MM 3.0 ASNIS SCREW,10084884,CDM,272,RC,,,Outpatient,,,840,840,,,,,,Other,Not Separately Reimbursable,693,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,693,82.5,,554.4,percent of total billed charges,Pays at 82.5% of total Billed charges,613.2,73,,490.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,588,70,,470.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,19.19,,128.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,420,50,,336,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,693,
PODIATRY - 2.3 LOCK L PLATE 6 HOLE,10084885,CDM,272,RC,,,Outpatient,,,1200,1200,,,,,,Other,Not Separately Reimbursable,990,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,990,82.5,,792,percent of total billed charges,Pays at 82.5% of total Billed charges,876,73,,700.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,840,70,,672,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,230.28,19.19,,184.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,600,50,,480,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,230.28,990,
PODIATRY - 10MM 2.3 LOCKING SCREW,10084886,CDM,272,RC,,,Outpatient,,,640,640,,,,,,Other,Not Separately Reimbursable,528,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,528,82.5,,422.4,percent of total billed charges,Pays at 82.5% of total Billed charges,467.2,73,,373.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,448,70,,358.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.82,19.19,,98.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,320,50,,256,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.82,528,
PODIATRY - 11MM 2.3 LOCKING SCREW,10084887,CDM,272,RC,,,Outpatient,,,560,560,,,,,,Other,Not Separately Reimbursable,462,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,462,82.5,,369.6,percent of total billed charges,Pays at 82.5% of total Billed charges,408.8,73,,327.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,392,70,,313.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.46,19.19,,85.968,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280,50,,224,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.46,462,
PODIATRY - 12MM 2.3 LOCKING SCREW,10084888,CDM,272,RC,,,Outpatient,,,570,570,,,,,,Other,Not Separately Reimbursable,470.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,470.25,82.5,,376.2,percent of total billed charges,Pays at 82.5% of total Billed charges,416.1,73,,332.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,399,70,,319.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.38,19.19,,87.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,285,50,,228,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.38,470.25,
POD / ORTHO - 13MM 2.3 LOCKING SCREW,10084889,CDM,272,RC,,,Outpatient,,,560,560,,,,,,Other,Not Separately Reimbursable,462,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,462,82.5,,369.6,percent of total billed charges,Pays at 82.5% of total Billed charges,408.8,73,,327.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,392,70,,313.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.46,19.19,,85.968,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280,50,,224,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.46,462,
PODIATRY - .8MM X100MM K WIRE,10084890,CDM,272,RC,,,Outpatient,,,210,210,,,,,,Other,Not Separately Reimbursable,173.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,173.25,82.5,,138.6,percent of total billed charges,Pays at 82.5% of total Billed charges,153.3,73,,122.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,70,,117.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,19.19,,32.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,50,,84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,173.25,
PODIATRY - CANNULATED DRILL 1.7,10084891,CDM,272,RC,,,Outpatient,,,1020,1020,,,,,,Other,Not Separately Reimbursable,841.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,841.5,82.5,,673.2,percent of total billed charges,Pays at 82.5% of total Billed charges,744.6,73,,595.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,714,70,,571.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,195.74,19.19,,156.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,510,50,,408,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,195.74,841.5,
PODIATRY - CANN 2.8MM COUNTER SINK,10084892,CDM,272,RC,,,Outpatient,,,1020,1020,,,,,,Other,Not Separately Reimbursable,841.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,841.5,82.5,,673.2,percent of total billed charges,Pays at 82.5% of total Billed charges,744.6,73,,595.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,714,70,,571.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,195.74,19.19,,156.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,510,50,,408,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,195.74,841.5,
PODIATRY - SCREW 16MM 2.0 ASNIS,10084893,CDM,272,RC,,,Outpatient,,,890,890,,,,,,Other,Not Separately Reimbursable,734.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,734.25,82.5,,587.4,percent of total billed charges,Pays at 82.5% of total Billed charges,649.7,73,,519.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,623,70,,498.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,19.19,,136.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,445,50,,356,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,734.25,
PODIATRY - COUNTERSINK 3.8MM,10084899,CDM,272,RC,,,Outpatient,,,820,820,,,,,,Other,Not Separately Reimbursable,676.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,676.5,82.5,,541.2,percent of total billed charges,Pays at 82.5% of total Billed charges,598.6,73,,478.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,574,70,,459.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.36,19.19,,125.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,410,50,,328,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.36,676.5,
O2 SENSOR (ADULT) MAX A,10084901,CDM,272,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
O2 SENSOR (PEDI) MAX P,10084902,CDM,272,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
O2 SENSOR (INFANT) MAX I,10084903,CDM,272,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
PODIATRY - SMART TOE 19,10084955,CDM,272,RC,,,Outpatient,,,2150,2150,,,,,,Other,Not Separately Reimbursable,1773.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1773.75,82.5,,1419,percent of total billed charges,Pays at 82.5% of total Billed charges,1569.5,73,,1255.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1505,70,,1204,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,412.59,19.19,,330.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1075,50,,860,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,412.59,1773.75,
PODIATRY - STOP DRILL 2MM,10084956,CDM,272,RC,,,Outpatient,,,310,310,,,,,,Other,Not Separately Reimbursable,255.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,255.75,82.5,,204.6,percent of total billed charges,Pays at 82.5% of total Billed charges,226.3,73,,181.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,217,70,,173.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,19.19,,47.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155,50,,124,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,255.75,
PODIATRY - ASNIS SCREW 2.0 18MM,10084957,CDM,272,RC,,,Outpatient,,,670,670,,,,,,Other,Not Separately Reimbursable,552.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,552.75,82.5,,442.2,percent of total billed charges,Pays at 82.5% of total Billed charges,489.1,73,,391.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,469,70,,375.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.57,19.19,,102.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,335,50,,268,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.57,552.75,
PODIATRY - COUNTERSINK 2.8,10084960,CDM,272,RC,,,Outpatient,,,1230,1230,,,,,,Other,Not Separately Reimbursable,1014.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1014.75,82.5,,811.8,percent of total billed charges,Pays at 82.5% of total Billed charges,897.9,73,,718.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,861,70,,688.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,236.04,19.19,,188.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,615,50,,492,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,236.04,1014.75,
PODIATRY - SCREW 15MM 2.0 ASNIS,10084961,CDM,272,RC,,,Outpatient,,,670,670,,,,,,Other,Not Separately Reimbursable,552.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,552.75,82.5,,442.2,percent of total billed charges,Pays at 82.5% of total Billed charges,489.1,73,,391.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,469,70,,375.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.57,19.19,,102.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,335,50,,268,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.57,552.75,
PODIATRY - 7 HOLE Y PLATE,10084990,CDM,272,RC,,,Outpatient,,,1170,1170,,,,,,Other,Not Separately Reimbursable,965.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,965.25,82.5,,772.2,percent of total billed charges,Pays at 82.5% of total Billed charges,854.1,73,,683.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,819,70,,655.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,224.52,19.19,,179.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,585,50,,468,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,224.52,965.25,
POD / ORTHO - 9MM BONE SCREW,10084992,CDM,272,RC,,,Outpatient,,,530,530,,,,,,Other,Not Separately Reimbursable,437.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,437.25,82.5,,349.8,percent of total billed charges,Pays at 82.5% of total Billed charges,386.9,73,,309.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371,70,,296.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,19.19,,81.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,265,50,,212,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,437.25,
PODIATRY - 8MM BONE SCREW,10084993,CDM,272,RC,,,Outpatient,,,640,640,,,,,,Other,Not Separately Reimbursable,528,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,528,82.5,,422.4,percent of total billed charges,Pays at 82.5% of total Billed charges,467.2,73,,373.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,448,70,,358.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.82,19.19,,98.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,320,50,,256,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.82,528,
POD / ORTHO - 9MM LOCKING SCREW,10084994,CDM,272,RC,,,Outpatient,,,640,640,,,,,,Other,Not Separately Reimbursable,528,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,528,82.5,,422.4,percent of total billed charges,Pays at 82.5% of total Billed charges,467.2,73,,373.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,448,70,,358.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.82,19.19,,98.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,320,50,,256,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.82,528,
PODIATRY - OLIVE TIP WIRE,10084995,CDM,272,RC,,,Outpatient,,,442,442,,,,,,Other,Not Separately Reimbursable,364.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,364.65,82.5,,291.72,percent of total billed charges,Pays at 82.5% of total Billed charges,322.66,73,,258.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,309.4,70,,247.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.82,19.19,,67.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,221,50,,176.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.82,364.65,
PODIATRY - 30MM 3.0 ASNIS SCREW,10084996,CDM,272,RC,,,Outpatient,,,840,840,,,,,,Other,Not Separately Reimbursable,693,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,693,82.5,,554.4,percent of total billed charges,Pays at 82.5% of total Billed charges,613.2,73,,490.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,588,70,,470.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,19.19,,128.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,420,50,,336,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,693,
PODIATRY - 24MM 3.0 ASNIS SCREW,10084997,CDM,272,RC,,,Outpatient,,,840,840,,,,,,Other,Not Separately Reimbursable,693,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,693,82.5,,554.4,percent of total billed charges,Pays at 82.5% of total Billed charges,613.2,73,,490.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,588,70,,470.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,19.19,,128.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,420,50,,336,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,693,
ORTHO PLATE (8 HOLE),10084999,CDM,271,RC,,,Outpatient,,,1540,1540,,,,,,Other,Not Separately Reimbursable,1270.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1270.5,82.5,,1016.4,percent of total billed charges,Pays at 82.5% of total Billed charges,1124.2,73,,899.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1078,70,,862.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,295.53,19.19,,236.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,770,50,,616,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,295.53,1270.5,
ORTHO BIO PUSHLOCK 3.5,10085002,CDM,271,RC,,,Outpatient,,,1390,1390,,,,,,Other,Not Separately Reimbursable,1146.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1146.75,82.5,,917.4,percent of total billed charges,Pays at 82.5% of total Billed charges,1014.7,73,,811.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,973,70,,778.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,266.74,19.19,,213.392,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,695,50,,556,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,266.74,1146.75,
ORTHO CORKSCREW SUTURE ANCHOR,10085003,CDM,271,RC,,,Outpatient,,,950,950,,,,,,Other,Not Separately Reimbursable,783.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,783.75,82.5,,627,percent of total billed charges,Pays at 82.5% of total Billed charges,693.5,73,,554.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,665,70,,532,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182.31,19.19,,145.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,475,50,,380,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182.31,783.75,
ORTHO SINGLE OATS 6MM SET,10085004,CDM,271,RC,,,Outpatient,,,2200,2200,,,,,,Other,Not Separately Reimbursable,1815,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1815,82.5,,1452,percent of total billed charges,Pays at 82.5% of total Billed charges,1606,73,,1284.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1540,70,,1232,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,422.18,19.19,,337.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1100,50,,880,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,422.18,1815,
ORTHO SINGLE OATS 8MM SET,10085005,CDM,271,RC,,,Outpatient,,,2200,2200,,,,,,Other,Not Separately Reimbursable,1815,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1815,82.5,,1452,percent of total billed charges,Pays at 82.5% of total Billed charges,1606,73,,1284.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1540,70,,1232,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,422.18,19.19,,337.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1100,50,,880,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,422.18,1815,
ORTHO SINGLE OATS 10MM SET,10085006,CDM,271,RC,,,Outpatient,,,2200,2200,,,,,,Other,Not Separately Reimbursable,1815,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1815,82.5,,1452,percent of total billed charges,Pays at 82.5% of total Billed charges,1606,73,,1284.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1540,70,,1232,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,422.18,19.19,,337.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1100,50,,880,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,422.18,1815,
ORTHO 5.5 FT BIO CORKSCREW,10085007,CDM,271,RC,,,Outpatient,,,1210,1210,,,,,,Other,Not Separately Reimbursable,998.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,998.25,82.5,,798.6,percent of total billed charges,Pays at 82.5% of total Billed charges,883.3,73,,706.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,847,70,,677.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,232.2,19.19,,185.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,605,50,,484,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,232.2,998.25,
ORTHOPEDIC PACK SPINE,10085008,CDM,272,RC,,,Outpatient,,,410,410,,,,,,Other,Not Separately Reimbursable,338.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,338.25,82.5,,270.6,percent of total billed charges,Pays at 82.5% of total Billed charges,299.3,73,,239.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,287,70,,229.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,19.19,,62.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205,50,,164,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,338.25,
ORTHO FIBERWIRE 2.0,10085009,CDM,271,RC,,,Outpatient,,,380,380,,,,,,Other,Not Separately Reimbursable,313.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,313.5,82.5,,250.8,percent of total billed charges,Pays at 82.5% of total Billed charges,277.4,73,,221.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,266,70,,212.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.92,19.19,,58.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,190,50,,152,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.92,313.5,
ORTHO TENODESIS DISK KIT,10085010,CDM,271,RC,,,Outpatient,,,950,950,,,,,,Other,Not Separately Reimbursable,783.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,783.75,82.5,,627,percent of total billed charges,Pays at 82.5% of total Billed charges,693.5,73,,554.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,665,70,,532,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182.31,19.19,,145.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,475,50,,380,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182.31,783.75,
ORTHO TENODESIS SCREW 7X23,10085011,CDM,271,RC,,,Outpatient,,,1120,1120,,,,,,Other,Not Separately Reimbursable,924,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,924,82.5,,739.2,percent of total billed charges,Pays at 82.5% of total Billed charges,817.6,73,,654.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,784,70,,627.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.93,19.19,,171.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,560,50,,448,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.93,924,
ORTHO 1.6MM SM BONE FIXATION,10085012,CDM,271,RC,,,Outpatient,,,970,970,,,,,,Other,Not Separately Reimbursable,800.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,800.25,82.5,,640.2,percent of total billed charges,Pays at 82.5% of total Billed charges,708.1,73,,566.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,679,70,,543.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.14,19.19,,148.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,485,50,,388,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.14,800.25,
ORTHOPEDIC PACK SHOLDER,10085013,CDM,272,RC,,,Outpatient,,,470,470,,,,,,Other,Not Separately Reimbursable,387.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,387.75,82.5,,310.2,percent of total billed charges,Pays at 82.5% of total Billed charges,343.1,73,,274.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329,70,,263.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,19.19,,72.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,235,50,,188,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,387.75,
ORTHO PRONE VIEW CUSHION,10085014,CDM,272,RC,,,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,93.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,93.23,82.5,,74.584,percent of total billed charges,Pays at 82.5% of total Billed charges,82.49,73,,65.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.1,70,,63.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,19.19,,17.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.5,50,,45.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,93.23,
ORTHO 3.5 LOCK SCREW 18MM,10085015,CDM,271,RC,,,Outpatient,,,380,380,,,,,,Other,Not Separately Reimbursable,313.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,313.5,82.5,,250.8,percent of total billed charges,Pays at 82.5% of total Billed charges,277.4,73,,221.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,266,70,,212.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.92,19.19,,58.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,190,50,,152,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.92,313.5,
ORTHO 3.5 CORT SCREW 24MM,10085016,CDM,271,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
ORTHO 3.5 CORT SCREW SELFTAP 12MM,10085017,CDM,271,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
ORTHO 3.5 LOCK SCREW 16MM,10085018,CDM,271,RC,,,Outpatient,,,400,400,,,,,,Other,Not Separately Reimbursable,330,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,330,82.5,,264,percent of total billed charges,Pays at 82.5% of total Billed charges,292,73,,233.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280,70,,224,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.76,19.19,,61.408,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,200,50,,160,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.76,330,
ORTHO 2.7 LOCK SCREW 12MM,10085019,CDM,271,RC,,,Outpatient,,,410,410,,,,,,Other,Not Separately Reimbursable,338.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,338.25,82.5,,270.6,percent of total billed charges,Pays at 82.5% of total Billed charges,299.3,73,,239.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,287,70,,229.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,19.19,,62.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205,50,,164,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,338.25,
ORTHO 2.7 LOCK SCREW 14MM,10085020,CDM,271,RC,,,Outpatient,,,420,420,,,,,,Other,Not Separately Reimbursable,346.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,346.5,82.5,,277.2,percent of total billed charges,Pays at 82.5% of total Billed charges,306.6,73,,245.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,294,70,,235.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.6,19.19,,64.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,210,50,,168,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.6,346.5,
ORTHO 3.5 LOCK SCREW 24MM,10085021,CDM,271,RC,,,Outpatient,,,400,400,,,,,,Other,Not Separately Reimbursable,330,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,330,82.5,,264,percent of total billed charges,Pays at 82.5% of total Billed charges,292,73,,233.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280,70,,224,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.76,19.19,,61.408,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,200,50,,160,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.76,330,
ORTHO 3.5 LOCK SCREW 28MM,10085022,CDM,271,RC,,,Outpatient,,,390,390,,,,,,Other,Not Separately Reimbursable,321.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,321.75,82.5,,257.4,percent of total billed charges,Pays at 82.5% of total Billed charges,284.7,73,,227.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,273,70,,218.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.84,19.19,,59.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,195,50,,156,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.84,321.75,
ORTHO 3.5 LOCK SCREW 32MM,10085023,CDM,271,RC,,,Outpatient,,,390,390,,,,,,Other,Not Separately Reimbursable,321.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,321.75,82.5,,257.4,percent of total billed charges,Pays at 82.5% of total Billed charges,284.7,73,,227.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,273,70,,218.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.84,19.19,,59.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,195,50,,156,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.84,321.75,
ORTHO 3.5 CORT SCREW 28MM,10085024,CDM,271,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
ORTHO FIB PLATE RGT 4 HOLE 80MM,10085026,CDM,271,RC,,,Outpatient,,,2120,2120,,,,,,Other,Not Separately Reimbursable,1749,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1749,82.5,,1399.2,percent of total billed charges,Pays at 82.5% of total Billed charges,1547.6,73,,1238.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1484,70,,1187.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,406.83,19.19,,325.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1060,50,,848,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,406.83,1749,
ORTHO RECONS PLATE 3.5MM 6 HOLE 81MML,10085027,CDM,271,RC,,,Outpatient,,,610,610,,,,,,Other,Not Separately Reimbursable,503.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,503.25,82.5,,402.6,percent of total billed charges,Pays at 82.5% of total Billed charges,445.3,73,,356.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,427,70,,341.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.06,19.19,,93.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,305,50,,244,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.06,503.25,
BLADE ELECTRODE BLUESILK 6,10085028,CDM,272,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
ORTHO K-WIRE 6 .035MM,10085031,CDM,271,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
ORTHO K-WIRE 4 .062MM,10085032,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
ORTHO K-WIRE 6 .045MM,10085033,CDM,271,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
ORTHO K-WIRE 1.6MM X 150MM,10085034,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
ORTHO K-WIRE 9 .45 1.1MM,10085035,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ORTHO K-WIRE 9 .62 1.6MM,10085036,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ORTHO K-WIRE 9 .62 1.6MM FULLY THREADED,10085037,CDM,271,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
ORTHO 2.7 LOCK SCREW 16MM,10085040,CDM,271,RC,,,Outpatient,,,420,420,,,,,,Other,Not Separately Reimbursable,346.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,346.5,82.5,,277.2,percent of total billed charges,Pays at 82.5% of total Billed charges,306.6,73,,245.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,294,70,,235.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.6,19.19,,64.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,210,50,,168,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.6,346.5,
ORTHO 2.7 LOCK SCREW 20MM,10085041,CDM,271,RC,,,Outpatient,,,410,410,,,,,,Other,Not Separately Reimbursable,338.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,338.25,82.5,,270.6,percent of total billed charges,Pays at 82.5% of total Billed charges,299.3,73,,239.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,287,70,,229.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,19.19,,62.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205,50,,164,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,338.25,
ORTHO 2.7 LOCK SCREW 24MM,10085042,CDM,271,RC,,,Outpatient,,,410,410,,,,,,Other,Not Separately Reimbursable,338.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,338.25,82.5,,270.6,percent of total billed charges,Pays at 82.5% of total Billed charges,299.3,73,,239.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,287,70,,229.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,19.19,,62.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205,50,,164,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,338.25,
ORTHO 2.7 LOCK SCREW 26MM,10085043,CDM,271,RC,,,Outpatient,,,410,410,,,,,,Other,Not Separately Reimbursable,338.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,338.25,82.5,,270.6,percent of total billed charges,Pays at 82.5% of total Billed charges,299.3,73,,239.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,287,70,,229.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,19.19,,62.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205,50,,164,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,338.25,
ORTHO PLATE ULNA LOCK RGT 5HL 10MM,10085044,CDM,271,RC,,,Outpatient,,,2560,2560,,,,,,Other,Not Separately Reimbursable,2112,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2112,82.5,,1689.6,percent of total billed charges,Pays at 82.5% of total Billed charges,1868.8,73,,1495.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1792,70,,1433.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,491.26,19.19,,393.008,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1280,50,,1024,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,491.26,2112,
ORTHO BONE VOID FILLER PASTE,10085045,CDM,271,RC,,,Outpatient,,,2290,2290,,,,,,Other,Not Separately Reimbursable,1889.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1889.25,82.5,,1511.4,percent of total billed charges,Pays at 82.5% of total Billed charges,1671.7,73,,1337.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1603,70,,1282.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,439.45,19.19,,351.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1145,50,,916,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,439.45,1889.25,
ORTHO 2.7MM CONICAL SCREW 18MM,10085046,CDM,271,RC,,,Outpatient,,,220,220,,,,,,Other,Not Separately Reimbursable,181.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,181.5,82.5,,145.2,percent of total billed charges,Pays at 82.5% of total Billed charges,160.6,73,,128.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154,70,,123.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,19.19,,33.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110,50,,88,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,181.5,
ORTHO 2.7MM CONICAL SCREW 24MM,10085047,CDM,271,RC,,,Outpatient,,,220,220,,,,,,Other,Not Separately Reimbursable,181.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,181.5,82.5,,145.2,percent of total billed charges,Pays at 82.5% of total Billed charges,160.6,73,,128.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154,70,,123.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,19.19,,33.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110,50,,88,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,181.5,
ORTHO 2.7MM CONICAL SCREW 26MM,10085048,CDM,271,RC,,,Outpatient,,,220,220,,,,,,Other,Not Separately Reimbursable,181.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,181.5,82.5,,145.2,percent of total billed charges,Pays at 82.5% of total Billed charges,160.6,73,,128.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154,70,,123.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,19.19,,33.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110,50,,88,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,181.5,
ORTHO 3.5MM PERI CORT SCREW 16MM,10085049,CDM,271,RC,,,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
ORTHO 3.5MM PERI CORT SCREW 22MM,10085050,CDM,271,RC,,,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
ORTHO 2.7MM CORT SELFTAP SCREW 40MM,10085051,CDM,271,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
ORTHO 4.0MM CANCELLOUS SCREW 30MM,10085052,CDM,271,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
BIOPSY NEEDLE JAM SHIDJ,10085053,CDM,271,RC,,,Outpatient,,,125,125,,,,,,Other,Not Separately Reimbursable,103.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,103.13,82.5,,82.504,percent of total billed charges,Pays at 82.5% of total Billed charges,91.25,73,,73,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,70,,70,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,19.19,,19.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.5,50,,50,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,103.13,
ORTHO K-WIRE GUIDEWIRE ZIMMER,10085054,CDM,271,RC,,,Outpatient,,,410,410,,,,,,Other,Not Separately Reimbursable,338.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,338.25,82.5,,270.6,percent of total billed charges,Pays at 82.5% of total Billed charges,299.3,73,,239.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,287,70,,229.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,19.19,,62.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205,50,,164,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,338.25,
ORTHO SCREW 6.5X 45MM ZIMMER,10085055,CDM,271,RC,,,Outpatient,,,2760,2760,,,,,,Other,Not Separately Reimbursable,2277,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2277,82.5,,1821.6,percent of total billed charges,Pays at 82.5% of total Billed charges,2014.8,73,,1611.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1932,70,,1545.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,529.64,19.19,,423.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1380,50,,1104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,529.64,2277,
ORTHO SCREW SET ZIMMER,10085056,CDM,271,RC,,,Outpatient,,,610,610,,,,,,Other,Not Separately Reimbursable,503.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,503.25,82.5,,402.6,percent of total billed charges,Pays at 82.5% of total Billed charges,445.3,73,,356.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,427,70,,341.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.06,19.19,,93.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,305,50,,244,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.06,503.25,
ORTHO ROD 50MM ZIMMER,10085057,CDM,271,RC,,,Outpatient,,,1210,1210,,,,,,Other,Not Separately Reimbursable,998.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,998.25,82.5,,798.6,percent of total billed charges,Pays at 82.5% of total Billed charges,883.3,73,,706.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,847,70,,677.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,232.2,19.19,,185.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,605,50,,484,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,232.2,998.25,
ORTHO EXPANDABLE CAGE PRO LIFT ZIMMER,10085058,CDM,271,RC,,,Outpatient,,,16010,16010,,,,,,Other,Not Separately Reimbursable,13208.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13208.25,82.5,,10566.6,percent of total billed charges,Pays at 82.5% of total Billed charges,11687.3,73,,9349.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11207,70,,8965.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3072.32,19.19,,2457.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8005,50,,6404,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3072.32,13208.25,
NUTECH SIFIX CORTICAL SACROILLIAC ALLOGR,10085059,CDM,271,RC,,,Outpatient,,,6260,6260,,,,,,Other,Not Separately Reimbursable,5164.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5164.5,82.5,,4131.6,percent of total billed charges,Pays at 82.5% of total Billed charges,4569.8,73,,3655.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4382,70,,3505.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1201.29,19.19,,961.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3130,50,,2504,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1201.29,5164.5,
ORTHO DISECTOR 3.0,10085067,CDM,271,RC,,,Outpatient,,,350,350,,,,,,Other,Not Separately Reimbursable,288.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,288.75,82.5,,231,percent of total billed charges,Pays at 82.5% of total Billed charges,255.5,73,,204.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245,70,,196,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.17,19.19,,53.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,50,,140,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.17,288.75,
ORTHO LEG HOLDER (CUSHION),10085068,CDM,271,RC,,,Outpatient,,,310,310,,,,,,Other,Not Separately Reimbursable,255.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,255.75,82.5,,204.6,percent of total billed charges,Pays at 82.5% of total Billed charges,226.3,73,,181.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,217,70,,173.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,19.19,,47.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155,50,,124,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,255.75,
ORTHO 3.5 LOCK SCREW 22MM,10085070,CDM,271,RC,,,Outpatient,,,410,410,,,,,,Other,Not Separately Reimbursable,338.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,338.25,82.5,,270.6,percent of total billed charges,Pays at 82.5% of total Billed charges,299.3,73,,239.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,287,70,,229.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,19.19,,62.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205,50,,164,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,338.25,
ORTHO 3.5 LOCK SCREW 20MM (IN/OUT),10085071,CDM,271,RC,,,Outpatient,,,410,410,,,,,,Other,Not Separately Reimbursable,338.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,338.25,82.5,,270.6,percent of total billed charges,Pays at 82.5% of total Billed charges,299.3,73,,239.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,287,70,,229.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,19.19,,62.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205,50,,164,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,338.25,
ORTHO 3.5 LOCK SCREW 14MM (IN/OUT),10085072,CDM,271,RC,,,Outpatient,,,400,400,,,,,,Other,Not Separately Reimbursable,330,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,330,82.5,,264,percent of total billed charges,Pays at 82.5% of total Billed charges,292,73,,233.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280,70,,224,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.76,19.19,,61.408,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,200,50,,160,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.76,330,
ORTHO 3.5 LOCK SCREW 26MM,10085073,CDM,271,RC,,,Outpatient,,,400,400,,,,,,Other,Not Separately Reimbursable,330,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,330,82.5,,264,percent of total billed charges,Pays at 82.5% of total Billed charges,292,73,,233.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280,70,,224,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.76,19.19,,61.408,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,200,50,,160,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.76,330,
ORTHO 3.5 (5HOLE) PLATE RECONSTRUCTION,10085074,CDM,271,RC,,,Outpatient,,,1190,1190,,,,,,Other,Not Separately Reimbursable,981.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,981.75,82.5,,785.4,percent of total billed charges,Pays at 82.5% of total Billed charges,868.7,73,,694.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,833,70,,666.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,228.36,19.19,,182.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595,50,,476,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,228.36,981.75,
ORTHO 3.5 CORT SCREW 14MM,10085075,CDM,271,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
ORTHO 3.5 CORT SCREW 18MM,10085076,CDM,271,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
ARTHREX FIBERTAPE,10085083,CDM,271,RC,,,Outpatient,,,185,185,,,,,,Other,Not Separately Reimbursable,152.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,152.63,82.5,,122.104,percent of total billed charges,Pays at 82.5% of total Billed charges,135.05,73,,108.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,129.5,70,,103.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,19.19,,28.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.5,50,,74,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,152.63,
ARTHREX TRIPLEDAM CANNULA,10085084,CDM,271,RC,,,Outpatient,,,145,145,,,,,,Other,Not Separately Reimbursable,119.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,119.63,82.5,,95.704,percent of total billed charges,Pays at 82.5% of total Billed charges,105.85,73,,84.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.5,70,,81.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.83,19.19,,22.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.5,50,,58,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.83,119.63,
"ARTHREX CRYSTAL CANNULA, SMOOTH",10085085,CDM,271,RC,,,Outpatient,,,600,600,,,,,,Other,Not Separately Reimbursable,495,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,495,82.5,,396,percent of total billed charges,Pays at 82.5% of total Billed charges,438,73,,350.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,420,70,,336,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.14,19.19,,92.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,300,50,,240,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.14,495,
ORTHO 2.7MM PERI CORT SCREW 14MM,10085088,CDM,271,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
ORTHO 3.5MM PERI CORT SCREW 14MM,10085089,CDM,271,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
PODIATRY - 2.6 AO DRILL,10085090,CDM,271,RC,,,Outpatient,,,790,790,,,,,,Other,Not Separately Reimbursable,651.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,651.75,82.5,,521.4,percent of total billed charges,Pays at 82.5% of total Billed charges,576.7,73,,461.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,553,70,,442.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.6,19.19,,121.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,395,50,,316,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.6,651.75,
ORTHO PLATE (6 HOLE),10085091,CDM,271,RC,,,Outpatient,,,1400,1400,,,,,,Other,Not Separately Reimbursable,1155,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1155,82.5,,924,percent of total billed charges,Pays at 82.5% of total Billed charges,1022,73,,817.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,980,70,,784,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,268.66,19.19,,214.928,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,700,50,,560,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,268.66,1155,
ORTHO GUIDE PIN,10085092,CDM,271,RC,,,Outpatient,,,370,370,,,,,,Other,Not Separately Reimbursable,305.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,305.25,82.5,,244.2,percent of total billed charges,Pays at 82.5% of total Billed charges,270.1,73,,216.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,259,70,,207.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,19.19,,56.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,185,50,,148,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,305.25,
ORTHO 3.5 LOCK SCREW 14MM,10085095,CDM,271,RC,,,Outpatient,,,420,420,,,,,,Other,Not Separately Reimbursable,346.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,346.5,82.5,,277.2,percent of total billed charges,Pays at 82.5% of total Billed charges,306.6,73,,245.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,294,70,,235.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.6,19.19,,64.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,210,50,,168,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.6,346.5,
ORTHO 3.5 (5HOLE) PLATE COMPRESSION,10085096,CDM,271,RC,,,Outpatient,,,870,870,,,,,,Other,Not Separately Reimbursable,717.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,717.75,82.5,,574.2,percent of total billed charges,Pays at 82.5% of total Billed charges,635.1,73,,508.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,609,70,,487.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.95,19.19,,133.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,435,50,,348,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.95,717.75,
ORTHO SCREW 7.0 X 105,10085099,CDM,271,RC,,,Outpatient,,,920,920,,,,,,Other,Not Separately Reimbursable,759,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,759,82.5,,607.2,percent of total billed charges,Pays at 82.5% of total Billed charges,671.6,73,,537.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,644,70,,515.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.55,19.19,,141.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,460,50,,368,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.55,759,
PULSAVAC PLUS (FAN KIT),10085101,CDM,272,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
PODIATRY - 2.5 OVERDRILL,10085111,CDM,272,RC,,,Outpatient,,,360,360,,,,,,Other,Not Separately Reimbursable,297,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,297,82.5,,237.6,percent of total billed charges,Pays at 82.5% of total Billed charges,262.8,73,,210.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252,70,,201.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,19.19,,55.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180,50,,144,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,297,
ORTHO - 1.9 100MM AO DRILL,10085112,CDM,272,RC,,,Outpatient,,,690,690,,,,,,Other,Not Separately Reimbursable,569.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,569.25,82.5,,455.4,percent of total billed charges,Pays at 82.5% of total Billed charges,503.7,73,,402.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,483,70,,386.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.41,19.19,,105.928,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,345,50,,276,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.41,569.25,
ORTHO ICONIX 25 SUTURE ANCHOR,10085120,CDM,271,RC,,,Outpatient,,,920,920,,,,,,Other,Not Separately Reimbursable,759,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,759,82.5,,607.2,percent of total billed charges,Pays at 82.5% of total Billed charges,671.6,73,,537.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,644,70,,515.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.55,19.19,,141.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,460,50,,368,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.55,759,
PODIATRY - 5 HOLE FIB PLATE,10085121,CDM,272,RC,,,Outpatient,,,1530,1530,,,,,,Other,Not Separately Reimbursable,1262.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1262.25,82.5,,1009.8,percent of total billed charges,Pays at 82.5% of total Billed charges,1116.9,73,,893.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1071,70,,856.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,293.61,19.19,,234.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,765,50,,612,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,293.61,1262.25,
PODIATRY - 14MM BONE SCREW,10085122,CDM,272,RC,,,Outpatient,,,530,530,,,,,,Other,Not Separately Reimbursable,437.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,437.25,82.5,,349.8,percent of total billed charges,Pays at 82.5% of total Billed charges,386.9,73,,309.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371,70,,296.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,19.19,,81.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,265,50,,212,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,437.25,
PODIATRY - 16MM BONE SCREW,10085123,CDM,272,RC,,,Outpatient,,,530,530,,,,,,Other,Not Separately Reimbursable,437.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,437.25,82.5,,349.8,percent of total billed charges,Pays at 82.5% of total Billed charges,386.9,73,,309.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371,70,,296.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,19.19,,81.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,265,50,,212,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,437.25,
PODIATRY - 20MM BONE SCREW,10085124,CDM,272,RC,,,Outpatient,,,220,220,,,,,,Other,Not Separately Reimbursable,181.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,181.5,82.5,,145.2,percent of total billed charges,Pays at 82.5% of total Billed charges,160.6,73,,128.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154,70,,123.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,19.19,,33.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110,50,,88,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,181.5,
PODIATRY - 14MM LOCKING SCREW,10085126,CDM,272,RC,,,Outpatient,,,500,500,,,,,,Other,Not Separately Reimbursable,412.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,412.5,82.5,,330,percent of total billed charges,Pays at 82.5% of total Billed charges,365,73,,292,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,350,70,,280,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.95,19.19,,76.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,250,50,,200,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.95,412.5,
PODIATRY - 12MM LOCKING SCREW,10085127,CDM,272,RC,,,Outpatient,,,500,500,,,,,,Other,Not Separately Reimbursable,412.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,412.5,82.5,,330,percent of total billed charges,Pays at 82.5% of total Billed charges,365,73,,292,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,350,70,,280,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.95,19.19,,76.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,250,50,,200,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.95,412.5,
PODIATRY - 16MM LOCKING SCREW,10085128,CDM,272,RC,,,Outpatient,,,500,500,,,,,,Other,Not Separately Reimbursable,412.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,412.5,82.5,,330,percent of total billed charges,Pays at 82.5% of total Billed charges,365,73,,292,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,350,70,,280,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.95,19.19,,76.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,250,50,,200,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.95,412.5,
PODIATRY - 1.4 K WIRE,10085129,CDM,272,RC,,,Outpatient,,,360,360,,,,,,Other,Not Separately Reimbursable,297,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,297,82.5,,237.6,percent of total billed charges,Pays at 82.5% of total Billed charges,262.8,73,,210.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252,70,,201.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,19.19,,55.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180,50,,144,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,297,
PODIATRY - 2.6MM AO DRILL,10085130,CDM,272,RC,,,Outpatient,,,420,420,,,,,,Other,Not Separately Reimbursable,346.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,346.5,82.5,,277.2,percent of total billed charges,Pays at 82.5% of total Billed charges,306.6,73,,245.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,294,70,,235.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.6,19.19,,64.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,210,50,,168,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.6,346.5,
PODIATRY - 3.5 OVER DRILL,10085131,CDM,272,RC,,,Outpatient,,,390,390,,,,,,Other,Not Separately Reimbursable,321.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,321.75,82.5,,257.4,percent of total billed charges,Pays at 82.5% of total Billed charges,284.7,73,,227.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,273,70,,218.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.84,19.19,,59.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,195,50,,156,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.84,321.75,
PODIATRY - 60MM BONE SCREW,10085132,CDM,272,RC,,,Outpatient,,,220,220,,,,,,Other,Not Separately Reimbursable,181.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,181.5,82.5,,145.2,percent of total billed charges,Pays at 82.5% of total Billed charges,160.6,73,,128.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154,70,,123.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,19.19,,33.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110,50,,88,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,181.5,
PODIATRY - SEMI TUBULAR PLATE,10085133,CDM,272,RC,,,Outpatient,,,1875,1875,,,,,,Other,Not Separately Reimbursable,1546.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1546.88,82.5,,1237.504,percent of total billed charges,Pays at 82.5% of total Billed charges,1368.75,73,,1095,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1312.5,70,,1050,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,359.81,19.19,,287.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,937.5,50,,750,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,359.81,1546.88,
PODIATRY - HEX CORTICAL SCREW 3.2,10085134,CDM,272,RC,,,Outpatient,,,640,640,,,,,,Other,Not Separately Reimbursable,528,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,528,82.5,,422.4,percent of total billed charges,Pays at 82.5% of total Billed charges,467.2,73,,373.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,448,70,,358.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.82,19.19,,98.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,320,50,,256,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.82,528,
PODIATRY - LOCKING SCREW 3.2MM,10085135,CDM,272,RC,,,Outpatient,,,640,640,,,,,,Other,Not Separately Reimbursable,528,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,528,82.5,,422.4,percent of total billed charges,Pays at 82.5% of total Billed charges,467.2,73,,373.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,448,70,,358.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.82,19.19,,98.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,320,50,,256,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.82,528,
PODIATRY -COMPRESSION SCREW 4.0MM,10085136,CDM,272,RC,,,Outpatient,,,1060,1060,,,,,,Other,Not Separately Reimbursable,874.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,874.5,82.5,,699.6,percent of total billed charges,Pays at 82.5% of total Billed charges,773.8,73,,619.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,742,70,,593.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.41,19.19,,162.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,530,50,,424,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.41,874.5,
PODIATRY - TWIST DRILL,10085137,CDM,272,RC,,,Outpatient,,,576,576,,,,,,Other,Not Separately Reimbursable,475.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,475.2,82.5,,380.16,percent of total billed charges,Pays at 82.5% of total Billed charges,420.48,73,,336.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,403.2,70,,322.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110.53,19.19,,88.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,288,50,,230.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110.53,475.2,
PODIATRY - INSTRUMENT FEE,10085138,CDM,272,RC,,,Outpatient,,,1000,1000,,,,,,Other,Not Separately Reimbursable,825,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,825,82.5,,660,percent of total billed charges,Pays at 82.5% of total Billed charges,730,73,,584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,700,70,,560,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191.9,19.19,,153.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,500,50,,400,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191.9,825,
PODIATRY - FLEX TOE IMP SZ 30,10085139,CDM,272,RC,,,Outpatient,,,4110,4110,,,,,,Other,Not Separately Reimbursable,3390.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3390.75,82.5,,2712.6,percent of total billed charges,Pays at 82.5% of total Billed charges,3000.3,73,,2400.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2877,70,,2301.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,788.71,19.19,,630.968,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2055,50,,1644,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,788.71,3390.75,
CATHETER STATLOCK STABILIZER,10085154,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
BURR 3MM X 12CM REX DRILL,10085191,CDM,272,RC,,,Outpatient,,,890,890,,,,,,Other,Not Separately Reimbursable,734.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,734.25,82.5,,587.4,percent of total billed charges,Pays at 82.5% of total Billed charges,649.7,73,,519.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,623,70,,498.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,19.19,,136.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,445,50,,356,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,734.25,
BURR 3MM MATCH HEAD REX DRILL,10085192,CDM,272,RC,,,Outpatient,,,800,800,,,,,,Other,Not Separately Reimbursable,660,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,660,82.5,,528,percent of total billed charges,Pays at 82.5% of total Billed charges,584,73,,467.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,560,70,,448,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153.52,19.19,,122.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,400,50,,320,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153.52,660,
BURR 3MM GREEN L REX DRILL,10085193,CDM,272,RC,,,Outpatient,,,910,910,,,,,,Other,Not Separately Reimbursable,750.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,750.75,82.5,,600.6,percent of total billed charges,Pays at 82.5% of total Billed charges,664.3,73,,531.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,637,70,,509.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.63,19.19,,139.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,455,50,,364,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.63,750.75,
BURR 6.0MM FLUTED 16 ROUND BEGGS,10085194,CDM,272,RC,,,Outpatient,,,270,270,,,,,,Other,Not Separately Reimbursable,222.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,222.75,82.5,,178.2,percent of total billed charges,Pays at 82.5% of total Billed charges,197.1,73,,157.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,189,70,,151.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.81,19.19,,41.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,135,50,,108,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.81,222.75,
BURR 4.7MM FLUTED 12 FLUTES,10085195,CDM,272,RC,,,Outpatient,,,260,260,,,,,,Other,Not Separately Reimbursable,214.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,214.5,82.5,,171.6,percent of total billed charges,Pays at 82.5% of total Billed charges,189.8,73,,151.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182,70,,145.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,19.19,,39.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,130,50,,104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,214.5,
BURR 5.0 / 6.0 ROUND FLUTED,10085196,CDM,272,RC,,,Outpatient,,,570,570,,,,,,Other,Not Separately Reimbursable,470.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,470.25,82.5,,376.2,percent of total billed charges,Pays at 82.5% of total Billed charges,416.1,73,,332.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,399,70,,319.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.38,19.19,,87.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,285,50,,228,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.38,470.25,
BURR 4.0 ROUND FLUTED 12 FLUTES,10085197,CDM,272,RC,,,Outpatient,,,260,260,,,,,,Other,Not Separately Reimbursable,214.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,214.5,82.5,,171.6,percent of total billed charges,Pays at 82.5% of total Billed charges,189.8,73,,151.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182,70,,145.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,19.19,,39.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,130,50,,104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,214.5,
BURR 4.0,10085198,CDM,272,RC,,,Outpatient,,,760,760,,,,,,Other,Not Separately Reimbursable,627,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,627,82.5,,501.6,percent of total billed charges,Pays at 82.5% of total Billed charges,554.8,73,,443.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,532,70,,425.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,145.84,19.19,,116.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,380,50,,304,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,145.84,627,
BURR 3MM X 12CM MH SMT REX DRILL,10085199,CDM,272,RC,,,Outpatient,,,890,890,,,,,,Other,Not Separately Reimbursable,734.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,734.25,82.5,,587.4,percent of total billed charges,Pays at 82.5% of total Billed charges,649.7,73,,519.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,623,70,,498.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,19.19,,136.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,445,50,,356,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,734.25,
PODIATRY - 4 HOLE FOOT PLATE,10085201,CDM,272,RC,,,Outpatient,,,1470,1470,,,,,,Other,Not Separately Reimbursable,1212.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1212.75,82.5,,970.2,percent of total billed charges,Pays at 82.5% of total Billed charges,1073.1,73,,858.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1029,70,,823.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,282.09,19.19,,225.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,735,50,,588,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,282.09,1212.75,
PODIATRY - 20MM 2.7 LOCK SCREW,10085202,CDM,272,RC,,,Outpatient,,,490,490,,,,,,Other,Not Separately Reimbursable,404.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,404.25,82.5,,323.4,percent of total billed charges,Pays at 82.5% of total Billed charges,357.7,73,,286.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,343,70,,274.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.03,19.19,,75.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245,50,,196,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.03,404.25,
PODIATRY - 16MM 2.7 LOCK SCREW,10085203,CDM,272,RC,,,Outpatient,,,490,490,,,,,,Other,Not Separately Reimbursable,404.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,404.25,82.5,,323.4,percent of total billed charges,Pays at 82.5% of total Billed charges,357.7,73,,286.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,343,70,,274.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.03,19.19,,75.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245,50,,196,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.03,404.25,
PODIATRY - 14MM 2.7 LOCK SCREW,10085204,CDM,272,RC,,,Outpatient,,,490,490,,,,,,Other,Not Separately Reimbursable,404.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,404.25,82.5,,323.4,percent of total billed charges,Pays at 82.5% of total Billed charges,357.7,73,,286.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,343,70,,274.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.03,19.19,,75.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245,50,,196,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.03,404.25,
PODIATRY - 34MM 4.0 ASNIS TI,10085205,CDM,272,RC,,,Outpatient,,,580,580,,,,,,Other,Not Separately Reimbursable,478.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,478.5,82.5,,382.8,percent of total billed charges,Pays at 82.5% of total Billed charges,423.4,73,,338.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,406,70,,324.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.3,19.19,,89.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,290,50,,232,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.3,478.5,
PODIATRY - COUNTER SINK,10085206,CDM,272,RC,,,Outpatient,,,820,820,,,,,,Other,Not Separately Reimbursable,676.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,676.5,82.5,,541.2,percent of total billed charges,Pays at 82.5% of total Billed charges,598.6,73,,478.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,574,70,,459.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.36,19.19,,125.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,410,50,,328,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.36,676.5,
PODIATRY - K WIRE 1.4X150MM,10085207,CDM,272,RC,,,Outpatient,,,490,490,,,,,,Other,Not Separately Reimbursable,404.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,404.25,82.5,,323.4,percent of total billed charges,Pays at 82.5% of total Billed charges,357.7,73,,286.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,343,70,,274.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.03,19.19,,75.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245,50,,196,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.03,404.25,
PODIATRY - 2.0 AO DRILL,10085208,CDM,272,RC,,,Outpatient,,,350,350,,,,,,Other,Not Separately Reimbursable,288.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,288.75,82.5,,231,percent of total billed charges,Pays at 82.5% of total Billed charges,255.5,73,,204.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245,70,,196,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.17,19.19,,53.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,50,,140,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.17,288.75,
PODIATRY - K WIRE 1.2X150MM,10085211,CDM,272,RC,,,Outpatient,,,330,330,,,,,,Other,Not Separately Reimbursable,272.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,272.25,82.5,,217.8,percent of total billed charges,Pays at 82.5% of total Billed charges,240.9,73,,192.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,231,70,,184.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.33,19.19,,50.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165,50,,132,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.33,272.25,
PODIATRY - 3.5 MM CN SCREW 42MM,10085212,CDM,272,RC,,,Outpatient,,,1060,1060,,,,,,Other,Not Separately Reimbursable,874.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,874.5,82.5,,699.6,percent of total billed charges,Pays at 82.5% of total Billed charges,773.8,73,,619.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,742,70,,593.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.41,19.19,,162.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,530,50,,424,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.41,874.5,
PODIATRY - 3.5 MM CN SCREW 24MM,10085213,CDM,272,RC,,,Outpatient,,,1060,1060,,,,,,Other,Not Separately Reimbursable,874.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,874.5,82.5,,699.6,percent of total billed charges,Pays at 82.5% of total Billed charges,773.8,73,,619.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,742,70,,593.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.41,19.19,,162.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,530,50,,424,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.41,874.5,
BURR 4MM OVAL 8 FLUTR 4.0MM X 13CM,10085214,CDM,272,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
SABRETOOTH CURVED 4.0MM X 13CM,10085215,CDM,272,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
SABRETOOTH 4.0MM X 13CM,10085216,CDM,272,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
ORTHO MAIN PUMP TUBING ARTHREX,10085217,CDM,272,RC,,,Outpatient,,,230,230,,,,,,Other,Not Separately Reimbursable,189.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,189.75,82.5,,151.8,percent of total billed charges,Pays at 82.5% of total Billed charges,167.9,73,,134.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161,70,,128.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.14,19.19,,35.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115,50,,92,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.14,189.75,
ORTHO - 8 HOLE H PLATE,10085229,CDM,272,RC,,,Outpatient,,,2030,2030,,,,,,Other,Not Separately Reimbursable,1674.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1674.75,82.5,,1339.8,percent of total billed charges,Pays at 82.5% of total Billed charges,1481.9,73,,1185.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1421,70,,1136.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,389.56,19.19,,311.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1015,50,,812,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,389.56,1674.75,
ORTHO - 10MM BONE SCREW,10085230,CDM,272,RC,,,Outpatient,,,530,530,,,,,,Other,Not Separately Reimbursable,437.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,437.25,82.5,,349.8,percent of total billed charges,Pays at 82.5% of total Billed charges,386.9,73,,309.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371,70,,296.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,19.19,,81.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,265,50,,212,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,437.25,
ORTHO - 11MM BONE SCREW,10085231,CDM,272,RC,,,Outpatient,,,550,550,,,,,,Other,Not Separately Reimbursable,453.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,453.75,82.5,,363,percent of total billed charges,Pays at 82.5% of total Billed charges,401.5,73,,321.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,385,70,,308,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.55,19.19,,84.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,275,50,,220,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.55,453.75,
ORTHO - 15MM BONE SCREW,10085232,CDM,272,RC,,,Outpatient,,,530,530,,,,,,Other,Not Separately Reimbursable,437.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,437.25,82.5,,349.8,percent of total billed charges,Pays at 82.5% of total Billed charges,386.9,73,,309.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371,70,,296.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,19.19,,81.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,265,50,,212,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,437.25,
PEDIATRIC URINE COLLECTOR,10085250,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
PODIATRY - SCREW 5MP OFF 20X13,10085271,CDM,272,RC,,,Outpatient,,,1000,1000,,,,,,Other,Not Separately Reimbursable,825,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,825,82.5,,660,percent of total billed charges,Pays at 82.5% of total Billed charges,730,73,,584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,700,70,,560,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191.9,19.19,,153.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,500,50,,400,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191.9,825,
PODIATRY - DRILL CANNULATED,10085296,CDM,272,RC,,,Outpatient,,,890,890,,,,,,Other,Not Separately Reimbursable,734.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,734.25,82.5,,587.4,percent of total billed charges,Pays at 82.5% of total Billed charges,649.7,73,,519.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,623,70,,498.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,19.19,,136.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,445,50,,356,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,734.25,
PODIATRY - 0MM 4.0 ASNIS TI,10085312,CDM,272,RC,,,Outpatient,,,820,820,,,,,,Other,Not Separately Reimbursable,676.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,676.5,82.5,,541.2,percent of total billed charges,Pays at 82.5% of total Billed charges,598.6,73,,478.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,574,70,,459.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.36,19.19,,125.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,410,50,,328,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.36,676.5,
PODIATRY - 4.0 WASHER,10085313,CDM,272,RC,,,Outpatient,,,125,125,,,,,,Other,Not Separately Reimbursable,103.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,103.13,82.5,,82.504,percent of total billed charges,Pays at 82.5% of total Billed charges,91.25,73,,73,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,70,,70,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,19.19,,19.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.5,50,,50,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,103.13,
PODIATRY - 15MM CANNULATED SCREW,10085417,CDM,272,RC,,,Outpatient,,,1060,1060,,,,,,Other,Not Separately Reimbursable,874.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,874.5,82.5,,699.6,percent of total billed charges,Pays at 82.5% of total Billed charges,773.8,73,,619.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,742,70,,593.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.41,19.19,,162.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,530,50,,424,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.41,874.5,
PODIATRY - 14MM CANNULATED SCREW,10085418,CDM,272,RC,,,Outpatient,,,1060,1060,,,,,,Other,Not Separately Reimbursable,874.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,874.5,82.5,,699.6,percent of total billed charges,Pays at 82.5% of total Billed charges,773.8,73,,619.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,742,70,,593.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.41,19.19,,162.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,530,50,,424,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.41,874.5,
PODIATRY - 10MM CANNULATED SCREW,10085419,CDM,272,RC,,,Outpatient,,,1060,1060,,,,,,Other,Not Separately Reimbursable,874.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,874.5,82.5,,699.6,percent of total billed charges,Pays at 82.5% of total Billed charges,773.8,73,,619.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,742,70,,593.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.41,19.19,,162.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,530,50,,424,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.41,874.5,
PODIATRY - K WIRE (P99-1920915),10085420,CDM,272,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
PODIATRY - 13MM CANNULATED SCREW,10085422,CDM,272,RC,,,Outpatient,,,1060,1060,,,,,,Other,Not Separately Reimbursable,874.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,874.5,82.5,,699.6,percent of total billed charges,Pays at 82.5% of total Billed charges,773.8,73,,619.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,742,70,,593.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.41,19.19,,162.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,530,50,,424,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.41,874.5,
PODIATRY - 17MM CANNULATED SCREW,10085442,CDM,272,RC,,,Outpatient,,,920,920,,,,,,Other,Not Separately Reimbursable,759,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,759,82.5,,607.2,percent of total billed charges,Pays at 82.5% of total Billed charges,671.6,73,,537.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,644,70,,515.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.55,19.19,,141.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,460,50,,368,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.55,759,
PODIATRY - 18MM CANNULATED SCREW,10085443,CDM,272,RC,,,Outpatient,,,920,920,,,,,,Other,Not Separately Reimbursable,759,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,759,82.5,,607.2,percent of total billed charges,Pays at 82.5% of total Billed charges,671.6,73,,537.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,644,70,,515.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.55,19.19,,141.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,460,50,,368,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.55,759,
PODIATRY - 14MM 3.0 ASNIS SCREW,10085444,CDM,272,RC,,,Outpatient,,,840,840,,,,,,Other,Not Separately Reimbursable,693,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,693,82.5,,554.4,percent of total billed charges,Pays at 82.5% of total Billed charges,613.2,73,,490.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,588,70,,470.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,19.19,,128.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,420,50,,336,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,693,
PODIATRY - 13MM 3.0 ASNIS SCREW,10085445,CDM,272,RC,,,Outpatient,,,840,840,,,,,,Other,Not Separately Reimbursable,693,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,693,82.5,,554.4,percent of total billed charges,Pays at 82.5% of total Billed charges,613.2,73,,490.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,588,70,,470.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,19.19,,128.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,420,50,,336,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,693,
PLEURX CAP,10085448,CDM,278,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,40,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,40,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,40,
CAST PLASTER BANDAGE 2,10085449,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CAST PLASTER BANDAGE 3,10085450,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CAST PLASTER BANDAGE 4,10085451,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CAST PLASTER BANDAGE 6,10085452,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CAST BOOT SMALL,10085453,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
CAST BOOT MEDIUM,10085454,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CAST BOOT LARGE,10085455,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CAST BOOT XLG,10085456,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
SPLINT WRIST LEFT UNIVERSAL,10085458,CDM,271,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
BOOT WALKER SMALL,10085459,CDM,271,RC,,,Outpatient,,,280,280,,,,,,Other,Not Separately Reimbursable,231,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,231,82.5,,184.8,percent of total billed charges,Pays at 82.5% of total Billed charges,204.4,73,,163.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,196,70,,156.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.73,19.19,,42.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,50,,112,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.73,231,
BOOT WALKER MEDIUM,10085460,CDM,271,RC,,,Outpatient,,,250,250,,,,,,Other,Not Separately Reimbursable,206.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,206.25,82.5,,165,percent of total billed charges,Pays at 82.5% of total Billed charges,182.5,73,,146,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,70,,140,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,19.19,,38.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125,50,,100,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,206.25,
BOOT WALKER LARGE,10085461,CDM,271,RC,,,Outpatient,,,360,360,,,,,,Other,Not Separately Reimbursable,297,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,297,82.5,,237.6,percent of total billed charges,Pays at 82.5% of total Billed charges,262.8,73,,210.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252,70,,201.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,19.19,,55.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180,50,,144,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,297,
ELBOW SLEEVE SMALL,10085462,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ELBOW SLEEVE MEDIUM,10085463,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ELBOW SLEEVE LARGE,10085464,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ELBOW SLEEVE XLARGE,10085465,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
KNEE BRACE HINGED SMALL,10085466,CDM,271,RC,,,Outpatient,,,180,180,,,,,,Other,Not Separately Reimbursable,148.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,148.5,82.5,,118.8,percent of total billed charges,Pays at 82.5% of total Billed charges,131.4,73,,105.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126,70,,100.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,19.19,,27.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90,50,,72,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,148.5,
KNEE BRACE HINGED MEDIUM,10085467,CDM,271,RC,,,Outpatient,,,240,240,,,,,,Other,Not Separately Reimbursable,198,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,198,82.5,,158.4,percent of total billed charges,Pays at 82.5% of total Billed charges,175.2,73,,140.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,168,70,,134.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.06,19.19,,36.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,120,50,,96,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.06,198,
KNEE BRACE HINGED LARGE,10085468,CDM,271,RC,,,Outpatient,,,180,180,,,,,,Other,Not Separately Reimbursable,148.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,148.5,82.5,,118.8,percent of total billed charges,Pays at 82.5% of total Billed charges,131.4,73,,105.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126,70,,100.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,19.19,,27.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90,50,,72,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,148.5,
KNEE BRACE HINGED X LG,10085469,CDM,271,RC,,,Outpatient,,,180,180,,,,,,Other,Not Separately Reimbursable,148.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,148.5,82.5,,118.8,percent of total billed charges,Pays at 82.5% of total Billed charges,131.4,73,,105.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126,70,,100.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,19.19,,27.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90,50,,72,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,148.5,
KNEE BRACE HINGED XXL,10085470,CDM,271,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
KNEE HINGED FOR PT,10085471,CDM,271,RC,,,Outpatient,,,710,710,,,,,,Other,Not Separately Reimbursable,585.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,585.75,82.5,,468.6,percent of total billed charges,Pays at 82.5% of total Billed charges,518.3,73,,414.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,497,70,,397.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,136.25,19.19,,109,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,355,50,,284,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,136.25,585.75,
PODIATRY - 14MM 2.0 ASNIS SCREW,10085496,CDM,272,RC,,,Outpatient,,,670,670,,,,,,Other,Not Separately Reimbursable,552.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,552.75,82.5,,442.2,percent of total billed charges,Pays at 82.5% of total Billed charges,489.1,73,,391.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,469,70,,375.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.57,19.19,,102.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,335,50,,268,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.57,552.75,
PODIATRY - 12MM 2.0 ASNIS SCREW,10085497,CDM,272,RC,,,Outpatient,,,910,910,,,,,,Other,Not Separately Reimbursable,750.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,750.75,82.5,,600.6,percent of total billed charges,Pays at 82.5% of total Billed charges,664.3,73,,531.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,637,70,,509.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.63,19.19,,139.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,455,50,,364,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.63,750.75,
PODIATRY - 10MM 2.0 ASNIS SCREW,10085498,CDM,272,RC,,,Outpatient,,,910,910,,,,,,Other,Not Separately Reimbursable,750.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,750.75,82.5,,600.6,percent of total billed charges,Pays at 82.5% of total Billed charges,664.3,73,,531.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,637,70,,509.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.63,19.19,,139.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,455,50,,364,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.63,750.75,
PENROSE DRAIN 1/4,10085525,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
PENROSE DRAIN 1/2,10085526,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
PLEUR EVAC - W (R/CHAMBER),10085549,CDM,278,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,190,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,190,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,190,
PLEUR EVAC (CHEST DRAIN),10085550,CDM,278,RC,,,Outpatient,,,340,340,,,,,,Other,Not Separately Reimbursable,340,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,340,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,248.2,73,,198.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,238,70,,190.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.25,19.19,,52.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170,50,,136,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.25,340,
ENDO GIA 60 - 3.8MM REFILL CARTRIDGE,10085551,CDM,272,RC,,,Outpatient,,,810,810,,,,,,Other,Not Separately Reimbursable,668.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,668.25,82.5,,534.6,percent of total billed charges,Pays at 82.5% of total Billed charges,591.3,73,,473.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,567,70,,453.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,19.19,,124.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,405,50,,324,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,668.25,
STAPLER TITANIUM TA 60 (4.8MM),10085552,CDM,272,RC,,,Outpatient,,,420,420,,,,,,Other,Not Separately Reimbursable,346.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,346.5,82.5,,277.2,percent of total billed charges,Pays at 82.5% of total Billed charges,306.6,73,,245.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,294,70,,235.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.6,19.19,,64.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,210,50,,168,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.6,346.5,
STAPLER TITANIUM TA 30,10085553,CDM,272,RC,,,Outpatient,,,340,340,,,,,,Other,Not Separately Reimbursable,280.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,280.5,82.5,,224.4,percent of total billed charges,Pays at 82.5% of total Billed charges,248.2,73,,198.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,238,70,,190.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.25,19.19,,52.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170,50,,136,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.25,280.5,
STAPLER TITANIUM TA 90,10085554,CDM,272,RC,,,Outpatient,,,440,440,,,,,,Other,Not Separately Reimbursable,363,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,363,82.5,,290.4,percent of total billed charges,Pays at 82.5% of total Billed charges,321.2,73,,256.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,308,70,,246.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.44,19.19,,67.552,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,220,50,,176,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.44,363,
ENDO GIA 60 - 3.8MM GUN (MULTIFIRE),10085555,CDM,272,RC,,,Outpatient,,,1140,1140,,,,,,Other,Not Separately Reimbursable,940.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,940.5,82.5,,752.4,percent of total billed charges,Pays at 82.5% of total Billed charges,832.2,73,,665.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,798,70,,638.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,218.77,19.19,,175.016,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,570,50,,456,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,218.77,940.5,
STAPLE REFILL TITANIUM TA 90 (4.8MM),10085556,CDM,272,RC,,,Outpatient,,,680,680,,,,,,Other,Not Separately Reimbursable,561,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,561,82.5,,448.8,percent of total billed charges,Pays at 82.5% of total Billed charges,496.4,73,,397.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,476,70,,380.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,130.49,19.19,,104.392,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,340,50,,272,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,130.49,561,
STAPLE REFILL TITANIUM TA 60,10085557,CDM,272,RC,,,Outpatient,,,340,340,,,,,,Other,Not Separately Reimbursable,280.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,280.5,82.5,,224.4,percent of total billed charges,Pays at 82.5% of total Billed charges,248.2,73,,198.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,238,70,,190.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.25,19.19,,52.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170,50,,136,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.25,280.5,
STAPLE REFILL TITANIUM TA 30 (4.8MM),10085558,CDM,272,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
ENDO GIA 80 - GUN (SINGLE USE),10085560,CDM,272,RC,,,Outpatient,,,650,650,,,,,,Other,Not Separately Reimbursable,536.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,536.25,82.5,,429,percent of total billed charges,Pays at 82.5% of total Billed charges,474.5,73,,379.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,455,70,,364,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124.74,19.19,,99.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,325,50,,260,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124.74,536.25,
ENDO GIA 80 - 3.8MM REFILL (SINGLE USE),10085561,CDM,272,RC,,,Outpatient,,,340,340,,,,,,Other,Not Separately Reimbursable,280.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,280.5,82.5,,224.4,percent of total billed charges,Pays at 82.5% of total Billed charges,248.2,73,,198.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,238,70,,190.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.25,19.19,,52.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170,50,,136,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.25,280.5,
WOUND PROTECTOR MEDIUM,10085562,CDM,272,RC,,,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
SCARLET RED,10085565,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
SPLINT PLASTER 2,10085586,CDM,271,RC,,,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
SPLINT PLASTER 3,10085588,CDM,271,RC,,,Outpatient,,,220,220,,,,,,Other,Not Separately Reimbursable,181.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,181.5,82.5,,145.2,percent of total billed charges,Pays at 82.5% of total Billed charges,160.6,73,,128.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154,70,,123.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,19.19,,33.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110,50,,88,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,181.5,
"DUAL SUMP, SILICONE AXIOM",10085589,CDM,272,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
SUCTION POOLE W/TUBE,10085600,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CYSTITOME 25GA,10085611,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
SPLINT - SWEDISH AFO,10085654,CDM,271,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
SPLINT - THERA PLUS HAND LEFT PT,10085655,CDM,271,RC,,,Outpatient,,,260,260,,,,,,Other,Not Separately Reimbursable,214.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,214.5,82.5,,171.6,percent of total billed charges,Pays at 82.5% of total Billed charges,189.8,73,,151.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182,70,,145.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,19.19,,39.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,130,50,,104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,214.5,
SPLINT WRIST RIGHT UNIVERSAL,10085656,CDM,271,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
TROCAR CATH 32FR .,10085657,CDM,272,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
TROCAR CATH 36FR .,10085658,CDM,272,RC,L4360,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
PT - WEDGE ABDUCTION FULL LEG,10085660,CDM,274,RC,,,Outpatient,,,310,310,,,,,,Other,Not Separately Reimbursable,255.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,255.75,82.5,,204.6,percent of total billed charges,Pays at 82.5% of total Billed charges,226.3,73,,181.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,217,70,,173.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,19.19,,47.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155,50,,124,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,255.75,
TROCAR CATH 40FR .,10085665,CDM,272,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
PEG ASSIST INSOLE MEN MEDIUM,10085670,CDM,271,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
STAPLE SKIN DISPOSABLE 15 SHOT,10085677,CDM,272,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
STAPLE SKIN DISPOSABLE 5 SHOT,10085679,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
GORTEX MESH 15cm X 19cm,10085680,CDM,278,RC,,,Outpatient,,,2820,2820,,,,,,Other,Not Separately Reimbursable,2820,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2820,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2058.6,73,,1646.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1974,70,,1579.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,541.16,19.19,,432.928,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1410,50,,1128,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,541.16,2820,
MESH SEPRA 8 X 12,10085681,CDM,278,RC,,,Outpatient,,,2930,2930,,,,,,Other,Not Separately Reimbursable,2930,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2930,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2138.9,73,,1711.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2051,70,,1640.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,562.27,19.19,,449.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1465,50,,1172,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,562.27,2930,
MESH VICRYL 12X12 (WOVEN),10085682,CDM,278,RC,,,Outpatient,,,2410,2410,,,,,,Other,Not Separately Reimbursable,2410,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2410,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1759.3,73,,1407.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1687,70,,1349.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,462.48,19.19,,369.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1205,50,,964,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,462.48,2410,
MESH SEPRA 6 X 8,10085683,CDM,278,RC,,,Outpatient,,,2960,2960,,,,,,Other,Not Separately Reimbursable,2960,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2960,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2160.8,73,,1728.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2072,70,,1657.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,568.02,19.19,,454.416,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1480,50,,1184,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,568.02,2960,
MESH SEPRA 4 X 6,10085684,CDM,278,RC,,,Outpatient,,,2180,2180,,,,,,Other,Not Separately Reimbursable,2180,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2180,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1591.4,73,,1273.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1526,70,,1220.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,418.34,19.19,,334.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1090,50,,872,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,418.34,2180,
PROTACKER 5MM,10085685,CDM,272,RC,,,Outpatient,,,2040,2040,,,,,,Other,Not Separately Reimbursable,1683,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1683,82.5,,1346.4,percent of total billed charges,Pays at 82.5% of total Billed charges,1489.2,73,,1191.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1428,70,,1142.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,391.48,19.19,,313.184,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1020,50,,816,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,391.48,1683,
MESH SEPRA 3 X 6,10085686,CDM,278,RC,,,Outpatient,,,1410,1410,,,,,,Other,Not Separately Reimbursable,1410,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1410,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1029.3,73,,823.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,987,70,,789.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,270.58,19.19,,216.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,705,50,,564,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,270.58,1410,
MESH TIMESH (TITANIUM POLYMERES),10085687,CDM,278,RC,,,Outpatient,,,910,910,,,,,,Other,Not Separately Reimbursable,910,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,910,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,664.3,73,,531.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,637,70,,509.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.63,19.19,,139.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,455,50,,364,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.63,910,
GORTEX MESH 10cm X 15cm 1DLMC03,10085688,CDM,278,RC,,,Outpatient,,,1860,1860,,,,,,Other,Not Separately Reimbursable,1860,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1860,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1357.8,73,,1086.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1302,70,,1041.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,356.93,19.19,,285.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,930,50,,744,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,356.93,1860,
SEPRA FILM (5 X 6 ),10085689,CDM,270,RC,,,Outpatient,,,850,850,,,,,,Other,Not Separately Reimbursable,701.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,701.25,82.5,,561,percent of total billed charges,Pays at 82.5% of total Billed charges,620.5,73,,496.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595,70,,476,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.12,19.19,,130.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,425,50,,340,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.12,701.25,
VERSAPORT PLUS 5MM - 12MM,10085696,CDM,272,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
VERSAPORT V2 5MM,10085698,CDM,272,RC,,,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
VERSAPORT PLUS 5MM - 11MM,10085699,CDM,272,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
VERSAPORT V2,10085700,CDM,272,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
ENT - VENT TUBE 7MM,10085701,CDM,271,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
ENT - VENT TUBE PEDIATRIC .76,10085702,CDM,271,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
ENT - 3MM TYMPANIC MEMBRANE PATCHER,10085703,CDM,271,RC,,,Outpatient,,,280,280,,,,,,Other,Not Separately Reimbursable,231,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,231,82.5,,184.8,percent of total billed charges,Pays at 82.5% of total Billed charges,204.4,73,,163.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,196,70,,156.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.73,19.19,,42.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,50,,112,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.73,231,
ENT - 5MM TYMPANIC MEMBRANE PATCHER,10085704,CDM,271,RC,,,Outpatient,,,280,280,,,,,,Other,Not Separately Reimbursable,231,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,231,82.5,,184.8,percent of total billed charges,Pays at 82.5% of total Billed charges,204.4,73,,163.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,196,70,,156.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.73,19.19,,42.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,50,,112,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.73,231,
ENT - PLASMA BLADE,10085705,CDM,271,RC,,,Outpatient,,,1000,1000,,,,,,Other,Not Separately Reimbursable,825,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,825,82.5,,660,percent of total billed charges,Pays at 82.5% of total Billed charges,730,73,,584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,700,70,,560,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191.9,19.19,,153.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,500,50,,400,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191.9,825,
ENT - 7MM TYMPANIC MEMBRANE PATCHER,10085706,CDM,271,RC,,,Outpatient,,,390,390,,,,,,Other,Not Separately Reimbursable,321.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,321.75,82.5,,257.4,percent of total billed charges,Pays at 82.5% of total Billed charges,284.7,73,,227.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,273,70,,218.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.84,19.19,,59.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,195,50,,156,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.84,321.75,
ENT - 10MM TYMPANIC MEMBRANE PATCHER,10085707,CDM,271,RC,,,Outpatient,,,370,370,,,,,,Other,Not Separately Reimbursable,305.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,305.25,82.5,,244.2,percent of total billed charges,Pays at 82.5% of total Billed charges,270.1,73,,216.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,259,70,,207.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,19.19,,56.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,185,50,,148,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,305.25,
ENT - NASAL SEPTAL BUTTON 3CM,10085708,CDM,271,RC,,,Outpatient,,,870,870,,,,,,Other,Not Separately Reimbursable,717.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,717.75,82.5,,574.2,percent of total billed charges,Pays at 82.5% of total Billed charges,635.1,73,,508.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,609,70,,487.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.95,19.19,,133.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,435,50,,348,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.95,717.75,
ENT - MEROPACK,10085710,CDM,271,RC,,,Outpatient,,,430,430,,,,,,Other,Not Separately Reimbursable,354.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,354.75,82.5,,283.8,percent of total billed charges,Pays at 82.5% of total Billed charges,313.9,73,,251.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,301,70,,240.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.52,19.19,,66.016,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,215,50,,172,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.52,354.75,
ENT - TRICUT BLADE,10085711,CDM,271,RC,,,Outpatient,,,730,730,,,,,,Other,Not Separately Reimbursable,602.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,602.25,82.5,,481.8,percent of total billed charges,Pays at 82.5% of total Billed charges,532.9,73,,426.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,511,70,,408.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140.09,19.19,,112.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,365,50,,292,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140.09,602.25,
ENT - TRICUT BLADE 2.9MM*,10085712,CDM,271,RC,,,Outpatient,,,730,730,,,,,,Other,Not Separately Reimbursable,602.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,602.25,82.5,,481.8,percent of total billed charges,Pays at 82.5% of total Billed charges,532.9,73,,426.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,511,70,,408.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140.09,19.19,,112.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,365,50,,292,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140.09,602.25,
ENT - TRICUT BLADE 4.3MM*,10085713,CDM,271,RC,,,Outpatient,,,780,780,,,,,,Other,Not Separately Reimbursable,643.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,643.5,82.5,,514.8,percent of total billed charges,Pays at 82.5% of total Billed charges,569.4,73,,455.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,546,70,,436.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.68,19.19,,119.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,390,50,,312,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.68,643.5,
ENT - TRICUT BLADE 13CM FUSION,10085714,CDM,271,RC,,,Outpatient,,,920,920,,,,,,Other,Not Separately Reimbursable,759,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,759,82.5,,607.2,percent of total billed charges,Pays at 82.5% of total Billed charges,671.6,73,,537.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,644,70,,515.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.55,19.19,,141.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,460,50,,368,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.55,759,
ENT - BALLOON SINUPLASTY SYSTEM RELIEVA,10085715,CDM,271,RC,,,Outpatient,,,4880,4880,,,,,,Other,Not Separately Reimbursable,4026,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4026,82.5,,3220.8,percent of total billed charges,Pays at 82.5% of total Billed charges,3562.4,73,,2849.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3416,70,,2732.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,936.47,19.19,,749.176,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2440,50,,1952,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,936.47,4026,
ENT - ETHMOID PUNCH RELIEVA CIRCA,10085716,CDM,271,RC,,,Outpatient,,,860,860,,,,,,Other,Not Separately Reimbursable,709.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,709.5,82.5,,567.6,percent of total billed charges,Pays at 82.5% of total Billed charges,627.8,73,,502.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,602,70,,481.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165.03,19.19,,132.024,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,430,50,,344,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165.03,709.5,
ENT - BALLOON INFLATION DEVICE ACCLARENT,10085717,CDM,271,RC,,,Outpatient,,,300,300,,,,,,Other,Not Separately Reimbursable,247.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,247.5,82.5,,198,percent of total billed charges,Pays at 82.5% of total Billed charges,219,73,,175.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,210,70,,168,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.57,19.19,,46.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,150,50,,120,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.57,247.5,
ENT - SUCT COAG PBLADE*,10085719,CDM,271,RC,,,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
ENT - EXT NASAL SPLINT SM,10085720,CDM,271,RC,,,Outpatient,,,210,210,,,,,,Other,Not Separately Reimbursable,173.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,173.25,82.5,,138.6,percent of total billed charges,Pays at 82.5% of total Billed charges,153.3,73,,122.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,70,,117.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,19.19,,32.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,50,,84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,173.25,
ENT - EXT NASAL SPLINT MD,10085721,CDM,271,RC,,,Outpatient,,,210,210,,,,,,Other,Not Separately Reimbursable,173.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,173.25,82.5,,138.6,percent of total billed charges,Pays at 82.5% of total Billed charges,153.3,73,,122.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,70,,117.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,19.19,,32.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,50,,84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,173.25,
ENT - EXT NASAL SPLINT LG,10085722,CDM,271,RC,,,Outpatient,,,210,210,,,,,,Other,Not Separately Reimbursable,173.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,173.25,82.5,,138.6,percent of total billed charges,Pays at 82.5% of total Billed charges,153.3,73,,122.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,70,,117.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,19.19,,32.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,50,,84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,173.25,
ENT - VARI STEM NERVE NEEDLE,10085749,CDM,271,RC,,,Outpatient,,,230,230,,,,,,Other,Not Separately Reimbursable,189.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,189.75,82.5,,151.8,percent of total billed charges,Pays at 82.5% of total Billed charges,167.9,73,,134.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161,70,,128.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.14,19.19,,35.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115,50,,92,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.14,189.75,
STAPLER ILS 29MM INTRALUMINAL,10085777,CDM,272,RC,,,Outpatient,,,2810,2810,,,,,,Other,Not Separately Reimbursable,2318.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2318.25,82.5,,1854.6,percent of total billed charges,Pays at 82.5% of total Billed charges,2051.3,73,,1641.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1967,70,,1573.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,539.24,19.19,,431.392,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1405,50,,1124,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,539.24,2318.25,
STAPLER ILS 25MM INTRALUMINAL,10085778,CDM,272,RC,,,Outpatient,,,2880,2880,,,,,,Other,Not Separately Reimbursable,2376,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2376,82.5,,1900.8,percent of total billed charges,Pays at 82.5% of total Billed charges,2102.4,73,,1681.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2016,70,,1612.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,552.67,19.19,,442.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1440,50,,1152,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,552.67,2376,
STAPLER ILS 28MM INTRALUMINAL,10085779,CDM,272,RC,,,Outpatient,,,2880,2880,,,,,,Other,Not Separately Reimbursable,2376,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2376,82.5,,1900.8,percent of total billed charges,Pays at 82.5% of total Billed charges,2102.4,73,,1681.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2016,70,,1612.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,552.67,19.19,,442.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1440,50,,1152,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,552.67,2376,
STAPLER ILS 31MM INTRALUMINAL,10085780,CDM,272,RC,,,Outpatient,,,2510,2510,,,,,,Other,Not Separately Reimbursable,2070.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2070.75,82.5,,1656.6,percent of total billed charges,Pays at 82.5% of total Billed charges,1832.3,73,,1465.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1757,70,,1405.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,481.67,19.19,,385.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1255,50,,1004,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,481.67,2070.75,
STAPLER PURSTRING 65MM,10085781,CDM,272,RC,,,Outpatient,,,920,920,,,,,,Other,Not Separately Reimbursable,759,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,759,82.5,,607.2,percent of total billed charges,Pays at 82.5% of total Billed charges,671.6,73,,537.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,644,70,,515.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.55,19.19,,141.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,460,50,,368,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.55,759,
STAPLER ENDOGIA 45MM ART VASCULAR RELOAD,10085782,CDM,272,RC,,,Outpatient,,,1380,1380,,,,,,Other,Not Separately Reimbursable,1138.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1138.5,82.5,,910.8,percent of total billed charges,Pays at 82.5% of total Billed charges,1007.4,73,,805.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,966,70,,772.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,264.82,19.19,,211.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,690,50,,552,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,264.82,1138.5,
STAPLER ENDOGIA 45MM ART MED/THICKRELOAD,10085783,CDM,272,RC,,,Outpatient,,,1500,1500,,,,,,Other,Not Separately Reimbursable,1237.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1237.5,82.5,,990,percent of total billed charges,Pays at 82.5% of total Billed charges,1095,73,,876,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1050,70,,840,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,287.85,19.19,,230.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,750,50,,600,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,287.85,1237.5,
STAPLER ENDOGIA ULTRA UNIVERSAL,10085784,CDM,272,RC,,,Outpatient,,,1190,1190,,,,,,Other,Not Separately Reimbursable,981.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,981.75,82.5,,785.4,percent of total billed charges,Pays at 82.5% of total Billed charges,868.7,73,,694.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,833,70,,666.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,228.36,19.19,,182.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595,50,,476,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,228.36,981.75,
STAPLER ENDOGIA ULTRA XL UNIVERSAL,10085785,CDM,272,RC,,,Outpatient,,,1430,1430,,,,,,Other,Not Separately Reimbursable,1179.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1179.75,82.5,,943.8,percent of total billed charges,Pays at 82.5% of total Billed charges,1043.9,73,,835.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1001,70,,800.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,274.42,19.19,,219.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,715,50,,572,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,274.42,1179.75,
STAPLER ILS 21 MM INTRALUMINAL,10085787,CDM,272,RC,,,Outpatient,,,1050,1050,,,,,,Other,Not Separately Reimbursable,866.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,866.25,82.5,,693,percent of total billed charges,Pays at 82.5% of total Billed charges,766.5,73,,613.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,735,70,,588,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,201.5,19.19,,161.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,525,50,,420,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,201.5,866.25,
OSTEOSET MINI BEAD 5CC,10085799,CDM,272,RC,,,Outpatient,,,1180,1180,,,,,,Other,Not Separately Reimbursable,973.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,973.5,82.5,,778.8,percent of total billed charges,Pays at 82.5% of total Billed charges,861.4,73,,689.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,826,70,,660.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,226.44,19.19,,181.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,590,50,,472,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,226.44,973.5,
RIB BELT - FEMALE UNIVERS,10085850,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
LAP DIST BALLOON,10085859,CDM,272,RC,,,Outpatient,,,440,440,,,,,,Other,Not Separately Reimbursable,363,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,363,82.5,,290.4,percent of total billed charges,Pays at 82.5% of total Billed charges,321.2,73,,256.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,308,70,,246.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.44,19.19,,67.552,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,220,50,,176,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.44,363,
RIB BELT - MALE UNIVER,10085860,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
PNEUMOTHORAX KIT,10085866,CDM,272,RC,,,Outpatient,,,310,310,,,,,,Other,Not Separately Reimbursable,255.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,255.75,82.5,,204.6,percent of total billed charges,Pays at 82.5% of total Billed charges,226.3,73,,181.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,217,70,,173.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,19.19,,47.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155,50,,124,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,255.75,
TRAY CRICOTHYROTOMY (TRACH),10085871,CDM,272,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
ROBNEL CATHETER 8FR,10085880,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ROBNEL CATHETER 10FR,10085881,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ROBNEL CATHETER 14FR,10085882,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ROBNEL CATHETER 16FR,10085883,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CATHETER ADAPTER FOLEY,10085884,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ROBNEL CATHETER 18FR,10085885,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
MULTI LUMEN CATH KIT ER,10085888,CDM,272,RC,,,Outpatient,,,260,260,,,,,,Other,Not Separately Reimbursable,214.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,214.5,82.5,,171.6,percent of total billed charges,Pays at 82.5% of total Billed charges,189.8,73,,151.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182,70,,145.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,19.19,,39.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,130,50,,104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,214.5,
TRACHEOSTOMY - SHILEY 4,10085889,CDM,272,RC,,,Outpatient,,,180,180,,,,,,Other,Not Separately Reimbursable,148.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,148.5,82.5,,118.8,percent of total billed charges,Pays at 82.5% of total Billed charges,131.4,73,,105.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126,70,,100.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,19.19,,27.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90,50,,72,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,148.5,
TRACHEOSTOMY - SHILEY 6,10085899,CDM,272,RC,,,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,123.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,123.75,82.5,,99,percent of total billed charges,Pays at 82.5% of total Billed charges,109.5,73,,87.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,70,,84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,19.19,,23.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75,50,,60,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,123.75,
CANNULA INNER 8.0MM,10085900,CDM,272,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
PODIATRY - VARIAX STRAIGHT PLATE,10085929,CDM,271,RC,,,Outpatient,,,2030,2030,,,,,,Other,Not Separately Reimbursable,1674.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1674.75,82.5,,1339.8,percent of total billed charges,Pays at 82.5% of total Billed charges,1481.9,73,,1185.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1421,70,,1136.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,389.56,19.19,,311.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1015,50,,812,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,389.56,1674.75,
PODIATRY - 3.5MM X24MM BONE SCREW,10085930,CDM,271,RC,,,Outpatient,,,530,530,,,,,,Other,Not Separately Reimbursable,437.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,437.25,82.5,,349.8,percent of total billed charges,Pays at 82.5% of total Billed charges,386.9,73,,309.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371,70,,296.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,19.19,,81.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,265,50,,212,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,437.25,
PODIATRY - PLATE LOCKING 1.7MM,10085931,CDM,271,RC,,,Outpatient,,,2210,2210,,,,,,Other,Not Separately Reimbursable,1823.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1823.25,82.5,,1458.6,percent of total billed charges,Pays at 82.5% of total Billed charges,1613.3,73,,1290.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1547,70,,1237.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,424.1,19.19,,339.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1105,50,,884,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,424.1,1823.25,
ORTHO - 2.3MM X 8MM BONE SCREW,10085932,CDM,272,RC,,,Outpatient,,,550,550,,,,,,Other,Not Separately Reimbursable,453.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,453.75,82.5,,363,percent of total billed charges,Pays at 82.5% of total Billed charges,401.5,73,,321.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,385,70,,308,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.55,19.19,,84.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,275,50,,220,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.55,453.75,
SUCTION IRRIGATOR - LAPOROSCOPY,10085950,CDM,272,RC,,,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
LAPAROSCOPIC GAS CONDITIONING SET,10085951,CDM,272,RC,,,Outpatient,,,250,250,,,,,,Other,Not Separately Reimbursable,206.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,206.25,82.5,,165,percent of total billed charges,Pays at 82.5% of total Billed charges,182.5,73,,146,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,70,,140,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,19.19,,38.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125,50,,100,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,206.25,
SALEM SUMP 5FR,10085972,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENTERAL FEEDING SET/W BAG,10085973,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
SALEM SUMP 10FR,10085974,CDM,272,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
SALEM SUMP 14FR,10085975,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SALEM SUMP 16FR,10085976,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SALEM SUMP 18FR,10085977,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SALEM SUMP - ANTI REFLUX VALVE,10085978,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CASSETTE INFLOW CROSSFLOW TUBING,10085979,CDM,272,RC,,,Outpatient,,,284,284,,,,,,Other,Not Separately Reimbursable,234.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,234.3,82.5,,187.44,percent of total billed charges,Pays at 82.5% of total Billed charges,207.32,73,,165.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,198.8,70,,159.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.5,19.19,,43.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,142,50,,113.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.5,234.3,
COAG IRRIG-J HOOK,10085985,CDM,272,RC,E0676,HCPCS,Outpatient,,,250,250,,,,,,Other,Not Separately Reimbursable,206.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,206.25,82.5,,165,percent of total billed charges,Pays at 82.5% of total Billed charges,182.5,73,,146,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,70,,140,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,19.19,,38.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125,50,,100,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,206.25,
GARMENT CALF COMPRESSION,10085989,CDM,271,RC,E0676,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
GARMENT LG CALF COMPRESSION,10085990,CDM,271,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
TRACHEOSTOMY - SHILEY 8,10085999,CDM,272,RC,,,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,123.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,123.75,82.5,,99,percent of total billed charges,Pays at 82.5% of total Billed charges,109.5,73,,87.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,70,,84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,19.19,,23.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75,50,,60,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,123.75,
ORTHO 3.5 CORT SCREW 22MM,10086008,CDM,271,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
ORTHO 3.5 CORT SCREW 20MM,10086010,CDM,271,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
DRESSING - VASELINE GAUZE,10086011,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CAST TUBULAR STOCKINETTE,10086016,CDM,271,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
ORTHO VDR PLATE LEFT,10086025,CDM,271,RC,,,Outpatient,,,3080,3080,,,,,,Other,Not Separately Reimbursable,2541,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2541,82.5,,2032.8,percent of total billed charges,Pays at 82.5% of total Billed charges,2248.4,73,,1798.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2156,70,,1724.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,591.05,19.19,,472.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1540,50,,1232,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,591.05,2541,
ORTHO VDU PLATE LEFT,10086026,CDM,271,RC,,,Outpatient,,,2880,2880,,,,,,Other,Not Separately Reimbursable,2376,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2376,82.5,,1900.8,percent of total billed charges,Pays at 82.5% of total Billed charges,2102.4,73,,1681.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2016,70,,1612.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,552.67,19.19,,442.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1440,50,,1152,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,552.67,2376,
ORTHO 2.0MM SURGIBIT DRILL,10086027,CDM,271,RC,,,Outpatient,,,470,470,,,,,,Other,Not Separately Reimbursable,387.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,387.75,82.5,,310.2,percent of total billed charges,Pays at 82.5% of total Billed charges,343.1,73,,274.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329,70,,263.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,19.19,,72.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,235,50,,188,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,387.75,
ORTHO 2.8MM SURGIBIT DRILL,10086028,CDM,271,RC,,,Outpatient,,,510,510,,,,,,Other,Not Separately Reimbursable,420.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,420.75,82.5,,336.6,percent of total billed charges,Pays at 82.5% of total Billed charges,372.3,73,,297.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,357,70,,285.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,19.19,,78.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255,50,,204,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,420.75,
ORTHO 1.5MM HEX DRIVER TIP,10086029,CDM,271,RC,L3650,HCPCS,Outpatient,,,870,870,,,,,,Other,Not Separately Reimbursable,717.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,717.75,82.5,,574.2,percent of total billed charges,Pays at 82.5% of total Billed charges,635.1,73,,508.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,609,70,,487.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.95,19.19,,133.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,435,50,,348,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.95,717.75,
SHOULDER IMMOBILIZER,10086030,CDM,274,RC,L3650,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
SHOULDER IMMOBILIZER - MD,10086031,CDM,274,RC,L3650,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
SHOULDER IMMOBILIZER - LG,10086032,CDM,274,RC,L3650,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
SHOULDER IMMOBILIZER - XL,10086033,CDM,274,RC,L3650,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
SHOULDER IMMOBILIZER - UNIV W/SLING-SWH,10086034,CDM,274,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ORTHO T15 HEXABLE DRIVER,10086040,CDM,271,RC,,,Outpatient,,,860,860,,,,,,Other,Not Separately Reimbursable,709.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,709.5,82.5,,567.6,percent of total billed charges,Pays at 82.5% of total Billed charges,627.8,73,,502.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,602,70,,481.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165.03,19.19,,132.024,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,430,50,,344,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165.03,709.5,
ORTHO T15 HEXABLE DRIVER,10086041,CDM,271,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
ORTHO 18MM 2.3 LOCK SCREW,10086042,CDM,271,RC,,,Outpatient,,,430,430,,,,,,Other,Not Separately Reimbursable,354.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,354.75,82.5,,283.8,percent of total billed charges,Pays at 82.5% of total Billed charges,313.9,73,,251.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,301,70,,240.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.52,19.19,,66.016,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,215,50,,172,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.52,354.75,
ORTHO 22MM 2.3 LOCK SCREW,10086043,CDM,271,RC,,,Outpatient,,,430,430,,,,,,Other,Not Separately Reimbursable,354.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,354.75,82.5,,283.8,percent of total billed charges,Pays at 82.5% of total Billed charges,313.9,73,,251.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,301,70,,240.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.52,19.19,,66.016,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,215,50,,172,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.52,354.75,
ORTHO 12MM 3.5 NL SCREW,10086044,CDM,271,RC,,,Outpatient,,,350,350,,,,,,Other,Not Separately Reimbursable,288.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,288.75,82.5,,231,percent of total billed charges,Pays at 82.5% of total Billed charges,255.5,73,,204.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245,70,,196,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.17,19.19,,53.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,50,,140,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.17,288.75,
ORTHO 14MM 3.5 NL SCREW,10086045,CDM,271,RC,,,Outpatient,,,350,350,,,,,,Other,Not Separately Reimbursable,288.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,288.75,82.5,,231,percent of total billed charges,Pays at 82.5% of total Billed charges,255.5,73,,204.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245,70,,196,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.17,19.19,,53.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,50,,140,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.17,288.75,
ORTHO 16MM 3.5 NL SCREW,10086046,CDM,271,RC,,,Outpatient,,,350,350,,,,,,Other,Not Separately Reimbursable,288.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,288.75,82.5,,231,percent of total billed charges,Pays at 82.5% of total Billed charges,255.5,73,,204.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245,70,,196,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.17,19.19,,53.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,50,,140,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.17,288.75,
ORTHO 2 MICRO DRILL,10086047,CDM,271,RC,,,Outpatient,,,890,890,,,,,,Other,Not Separately Reimbursable,734.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,734.25,82.5,,587.4,percent of total billed charges,Pays at 82.5% of total Billed charges,649.7,73,,519.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,623,70,,498.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,19.19,,136.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,445,50,,356,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,734.25,
ORTHO 2 MINI LONG DRILL,10086048,CDM,271,RC,,,Outpatient,,,890,890,,,,,,Other,Not Separately Reimbursable,734.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,734.25,82.5,,587.4,percent of total billed charges,Pays at 82.5% of total Billed charges,649.7,73,,519.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,623,70,,498.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,19.19,,136.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,445,50,,356,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,734.25,
ORTHO .035 WIRE,10086049,CDM,271,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
ORTHO .045 WIRE,10086050,CDM,271,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
ORTHO 28MM MICRO SCREW,10086051,CDM,271,RC,,,Outpatient,,,1590,1590,,,,,,Other,Not Separately Reimbursable,1311.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1311.75,82.5,,1049.4,percent of total billed charges,Pays at 82.5% of total Billed charges,1160.7,73,,928.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1113,70,,890.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,305.12,19.19,,244.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,795,50,,636,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,305.12,1311.75,
ORTHO 30MM MICRO SCREW,10086052,CDM,271,RC,,,Outpatient,,,1590,1590,,,,,,Other,Not Separately Reimbursable,1311.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1311.75,82.5,,1049.4,percent of total billed charges,Pays at 82.5% of total Billed charges,1160.7,73,,928.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1113,70,,890.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,305.12,19.19,,244.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,795,50,,636,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,305.12,1311.75,
ORTHO BONE GRAFT,10086053,CDM,271,RC,,,Outpatient,,,5140,5140,,,,,,Other,Not Separately Reimbursable,4240.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4240.5,82.5,,3392.4,percent of total billed charges,Pays at 82.5% of total Billed charges,3752.2,73,,3001.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3598,70,,2878.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,986.37,19.19,,789.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2570,50,,2056,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,986.37,4240.5,
ORTHO 3.5 LOCK SCREW 18MM (IN/OUT),10086055,CDM,271,RC,,,Outpatient,,,420,420,,,,,,Other,Not Separately Reimbursable,346.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,346.5,82.5,,277.2,percent of total billed charges,Pays at 82.5% of total Billed charges,306.6,73,,245.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,294,70,,235.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.6,19.19,,64.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,210,50,,168,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.6,346.5,
ORTHO 12MM DISRACTION PIN SCREWS SHARP S,10086056,CDM,271,RC,,,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
ORTHO 14MM DISRACTION PIN SCREWS SHARP S,10086057,CDM,271,RC,,,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
SITZ BATH KIT,10086075,CDM,271,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
ORTHO 2.7MM CORT SELFTAP SCREW 14MM,10086100,CDM,271,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
ORTHO 2.7MM CORT SELFTAP SCREW 16MM,10086101,CDM,271,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
ORTHO K-WIRE 1.25MM DIA / 150MM,10086102,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
ORTHO K-WIRE 2.0MM DIA / 150MM,10086103,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
PODIATRY - FIBULA PLATE 4 HOLE,10086121,CDM,272,RC,,,Outpatient,,,1530,1530,,,,,,Other,Not Separately Reimbursable,1262.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1262.25,82.5,,1009.8,percent of total billed charges,Pays at 82.5% of total Billed charges,1116.9,73,,893.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1071,70,,856.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,293.61,19.19,,234.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,765,50,,612,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,293.61,1262.25,
PODIATRY - BONE SCREW 18MM,10086122,CDM,272,RC,,,Outpatient,,,530,530,,,,,,Other,Not Separately Reimbursable,437.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,437.25,82.5,,349.8,percent of total billed charges,Pays at 82.5% of total Billed charges,386.9,73,,309.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371,70,,296.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,19.19,,81.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,265,50,,212,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,437.25,
PODIATRY - BONE SCREW 12MM,10086124,CDM,272,RC,,,Outpatient,,,530,530,,,,,,Other,Not Separately Reimbursable,437.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,437.25,82.5,,349.8,percent of total billed charges,Pays at 82.5% of total Billed charges,386.9,73,,309.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371,70,,296.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,19.19,,81.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,265,50,,212,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,437.25,
PODIATRY - ASNIS 38MM,10086128,CDM,272,RC,,,Outpatient,,,580,580,,,,,,Other,Not Separately Reimbursable,478.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,478.5,82.5,,382.8,percent of total billed charges,Pays at 82.5% of total Billed charges,423.4,73,,338.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,406,70,,324.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.3,19.19,,89.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,290,50,,232,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.3,478.5,
PODIATRY - ASNIS 46MM,10086129,CDM,272,RC,,,Outpatient,,,580,580,,,,,,Other,Not Separately Reimbursable,478.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,478.5,82.5,,382.8,percent of total billed charges,Pays at 82.5% of total Billed charges,423.4,73,,338.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,406,70,,324.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.3,19.19,,89.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,290,50,,232,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.3,478.5,
PODIATRY - TI WASHER,10086130,CDM,272,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
PODIATRY - ANCHOR SUTURE,10086131,CDM,272,RC,,,Outpatient,,,1510,1510,,,,,,Other,Not Separately Reimbursable,1245.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1245.75,82.5,,996.6,percent of total billed charges,Pays at 82.5% of total Billed charges,1102.3,73,,881.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1057,70,,845.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,289.77,19.19,,231.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,755,50,,604,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,289.77,1245.75,
PODIATRY - FORCE FIBER,10086132,CDM,272,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
SUCTION DAILY RENTAL,10086150,CDM,278,RC,L3808,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,20,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,20,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,20,
SPLINT W/F UNIV RIGHT,10086185,CDM,274,RC,L3808,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
SPLINT W/F UNIV LEFT,10086186,CDM,274,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
ANES STIMUPLEX NEEDLE,10086221,CDM,272,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
PUMP ACCUFUSER PAIN,10086222,CDM,272,RC,,,Outpatient,,,610,610,,,,,,Other,Not Separately Reimbursable,503.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,503.25,82.5,,402.6,percent of total billed charges,Pays at 82.5% of total Billed charges,445.3,73,,356.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,427,70,,341.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.06,19.19,,93.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,305,50,,244,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.06,503.25,
PUMP ACCUFUSER PLUS ANESTHESIA,10086223,CDM,272,RC,,,Outpatient,,,960,960,,,,,,Other,Not Separately Reimbursable,792,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,792,82.5,,633.6,percent of total billed charges,Pays at 82.5% of total Billed charges,700.8,73,,560.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,672,70,,537.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,184.22,19.19,,147.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,480,50,,384,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,184.22,792,
STOMACH LEVIN TUBE 12 FR,10086224,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
STOMACH LEVIN TUBE 14 FR,10086225,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
STOMACH LEVIN TUBE 16 FR,10086227,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
STOMACH LEVIN TUBE 18 FR,10086229,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
G-TUBE FLEXIFLOW 16 FR,10086231,CDM,272,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
G-TUBE FLEXIFLOW 18 FR,10086232,CDM,272,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
G-TUBE FLEXIFLOW 20 FR,10086233,CDM,272,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
G-TUBE FLEXIFLOW 22 FR,10086234,CDM,270,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
STOMACH LEVIN TUBE 5 FR,10086240,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
STOMACH LEVIN TUBE 10 FR,10086241,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SUCTION CANISTER 12000ml - OR,10086252,CDM,272,RC,,,Outpatient,,,73,73,,,,,,Other,Not Separately Reimbursable,60.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,60.23,82.5,,48.184,percent of total billed charges,Pays at 82.5% of total Billed charges,53.29,73,,42.632,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.1,70,,40.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.01,19.19,,11.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.5,50,,29.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.01,60.23,
SUCTION CANISTER,10086253,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
EVAC BOTTLE 500ML,10086254,CDM,272,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
EVAC BOTTLE 1000ML,10086255,CDM,272,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
EVAC BAGS 600ML,10086256,CDM,272,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
SPONGE DRAIN 4X4 BX/50,10086523,CDM,270,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
SPONGE DRAIN (EACH),10086524,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SHOE POST-OP MALE MED,10086553,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
SHOE POST-OP MALE LGD,10086554,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
SHOE POST-OP FEMALE MED,10086555,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
SHOE POST-OP FEMALE LG,10086556,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
SHOE DARCO M/S MEN LG,10086558,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
SHOE DARCO M/S MEN XLG,10086559,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
SHOE DARCO M/S WM MD,10086560,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
SHOE DARCO M/S WM LG,10086561,CDM,271,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
ENDOTRACH TUBE STYLET 5/12,10086595,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
NASAL RHINO ROCKET SMALL,10086672,CDM,272,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
NASAL RHINO ROCKET MEDIUM,10086673,CDM,272,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
NASAL RHINO ROCKET LARGE,10086674,CDM,272,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
STOP COCK 3 WAY,10086700,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
STOP COCK ANES D300,10086701,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SUCTION CATHETER 8FR,10086725,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SUCTION CATHETER 10FR,10086726,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SUCTION CATHETER KIT 12FR,10086750,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SUCTION CATHETER KIT 14FR,10086751,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SUCTION CATHETER KIT 18FR,10086753,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CONNECTOR 5-N-1,10086754,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
TRACHEOSTOMY CARE KIT,10086875,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
TROCAR KIT W/ 28FR CATH,10086900,CDM,272,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
T-TUBE ARMSTRONG GROMMET,10086911,CDM,272,RC,A6530,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
T E D KNEE XLG/REGULAR,10086919,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
T-TUBE FIRM SILICONE,10086922,CDM,272,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
T-TUBE SILICONE 9.5MM,10086923,CDM,272,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
T-TUBE BIOLITE 9.5MM,10086924,CDM,272,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
T-TUBE DRAIN 14FR,10086925,CDM,272,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
T-TUBE MICROGEL 9.8MM,10086926,CDM,272,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
T-TUBE ACTIVENT 9.5MM,10086927,CDM,272,RC,A6530,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
T E D KNEE LRG/LONG,10086928,CDM,271,RC,A6530,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
T E D KNEE LRG/REGULAR,10086929,CDM,271,RC,A6533,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
T E D THIGH SM/LONG,10086930,CDM,271,RC,A6530,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
T E D KNEE SM/REGULAR,10086931,CDM,271,RC,A6533,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
T E D THIGH MED/SHORT,10086932,CDM,271,RC,A6533,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
T E D THIGH MED/REGULAR,10086933,CDM,271,RC,A6533,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
T E D THIGH MED/LONG,10086934,CDM,271,RC,A6533,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
T E D THIGH LG/SHORT,10086935,CDM,271,RC,A6533,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
T E D THIGH LG/REGULAR,10086936,CDM,271,RC,A6530,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
T E D KNEE MED/REGULAR,10086937,CDM,271,RC,A6530,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
T E D KNEE MD/LONG,10086938,CDM,271,RC,A6530,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
T E D KNEE XLG/LONG,10086939,CDM,271,RC,A6533,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
T E D THIGH LG/LONG,10086940,CDM,271,RC,L3808,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
SPLINT W/F VELCRO R/SM,10086941,CDM,274,RC,A6533,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
T E D THIGH XLG/LONG,10086947,CDM,271,RC,A6533,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
T E D THIGH SMALL/REG,10086948,CDM,271,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
DRESSING - TELFA 3X8 EACH,10086951,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - TELFA PADS 3X4 EACH,10086952,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DRESSING - TEGADERM 4-3/4X4-3/4 SECUREME,10086953,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FLUID COLLECTION BAG W/WICK,10086965,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CATHETER TEXAS,10087000,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
PODIATRY - 2.4 X 20MM NL SCREW,10087120,CDM,272,RC,,,Outpatient,,,510,510,,,,,,Other,Not Separately Reimbursable,420.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,420.75,82.5,,336.6,percent of total billed charges,Pays at 82.5% of total Billed charges,372.3,73,,297.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,357,70,,285.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,19.19,,78.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255,50,,204,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,420.75,
PODIATRY - 2.4 X 18MM NL SCREW,10087121,CDM,272,RC,,,Outpatient,,,510,510,,,,,,Other,Not Separately Reimbursable,420.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,420.75,82.5,,336.6,percent of total billed charges,Pays at 82.5% of total Billed charges,372.3,73,,297.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,357,70,,285.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,19.19,,78.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255,50,,204,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,420.75,
PODIATRY - 2.4 X 12MM NL SCREW,10087122,CDM,272,RC,,,Outpatient,,,510,510,,,,,,Other,Not Separately Reimbursable,420.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,420.75,82.5,,336.6,percent of total billed charges,Pays at 82.5% of total Billed charges,372.3,73,,297.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,357,70,,285.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,19.19,,78.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255,50,,204,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,420.75,
PODIATRY - 2.4 X 10MM LK SCREW,10087123,CDM,272,RC,,,Outpatient,,,510,510,,,,,,Other,Not Separately Reimbursable,420.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,420.75,82.5,,336.6,percent of total billed charges,Pays at 82.5% of total Billed charges,372.3,73,,297.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,357,70,,285.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,19.19,,78.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255,50,,204,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,420.75,
PODIATRY - 2.4 X 20MM LK SCREW,10087124,CDM,272,RC,,,Outpatient,,,510,510,,,,,,Other,Not Separately Reimbursable,420.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,420.75,82.5,,336.6,percent of total billed charges,Pays at 82.5% of total Billed charges,372.3,73,,297.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,357,70,,285.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,19.19,,78.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255,50,,204,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,420.75,
PODIATRY - PLATE 4 HOLE MINI MAX,10087125,CDM,272,RC,,,Outpatient,,,3010,3010,,,,,,Other,Not Separately Reimbursable,2483.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2483.25,82.5,,1986.6,percent of total billed charges,Pays at 82.5% of total Billed charges,2197.3,73,,1757.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2107,70,,1685.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,577.62,19.19,,462.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1505,50,,1204,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,577.62,2483.25,
PODIATRY - 1.9MM DRILL BIT,10087133,CDM,272,RC,,,Outpatient,,,810,810,,,,,,Other,Not Separately Reimbursable,668.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,668.25,82.5,,534.6,percent of total billed charges,Pays at 82.5% of total Billed charges,591.3,73,,473.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,567,70,,453.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,19.19,,124.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,405,50,,324,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.44,668.25,
PODIATRY - 2.7 X 18 MM LOCK SCREW,10087134,CDM,272,RC,,,Outpatient,,,510,510,,,,,,Other,Not Separately Reimbursable,420.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,420.75,82.5,,336.6,percent of total billed charges,Pays at 82.5% of total Billed charges,372.3,73,,297.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,357,70,,285.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,19.19,,78.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255,50,,204,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,420.75,
PODIATRY - 2.7MM X18 LOCK SCREW,10087135,CDM,272,RC,,,Outpatient,,,510,510,,,,,,Other,Not Separately Reimbursable,420.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,420.75,82.5,,336.6,percent of total billed charges,Pays at 82.5% of total Billed charges,372.3,73,,297.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,357,70,,285.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,19.19,,78.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255,50,,204,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,420.75,
PODIATRY - 2.7MM X20 LOCK SCREW,10087136,CDM,272,RC,,,Outpatient,,,510,510,,,,,,Other,Not Separately Reimbursable,420.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,420.75,82.5,,336.6,percent of total billed charges,Pays at 82.5% of total Billed charges,372.3,73,,297.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,357,70,,285.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,19.19,,78.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255,50,,204,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,420.75,
PODIATRY - 2.7MM X18 NON LOCK SCREW,10087137,CDM,272,RC,,,Outpatient,,,510,510,,,,,,Other,Not Separately Reimbursable,420.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,420.75,82.5,,336.6,percent of total billed charges,Pays at 82.5% of total Billed charges,372.3,73,,297.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,357,70,,285.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,19.19,,78.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255,50,,204,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,420.75,
PODIATRY - PLATE 4 HOLE ALPHA Y,10087138,CDM,272,RC,,,Outpatient,,,3010,3010,,,,,,Other,Not Separately Reimbursable,2483.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2483.25,82.5,,1986.6,percent of total billed charges,Pays at 82.5% of total Billed charges,2197.3,73,,1757.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2107,70,,1685.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,577.62,19.19,,462.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1505,50,,1204,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,577.62,2483.25,
PODIATRY - GUIDEWIRE .9 DBL TROCAR,10087155,CDM,272,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
PODIATRY - DRILL BIT 2MM,10087156,CDM,272,RC,,,Outpatient,,,970,970,,,,,,Other,Not Separately Reimbursable,800.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,800.25,82.5,,640.2,percent of total billed charges,Pays at 82.5% of total Billed charges,708.1,73,,566.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,679,70,,543.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.14,19.19,,148.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,485,50,,388,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.14,800.25,
PODIATRY - SCREW 2.5 X 14MM LONG THREAD,10087157,CDM,272,RC,,,Outpatient,,,940,940,,,,,,Other,Not Separately Reimbursable,775.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,775.5,82.5,,620.4,percent of total billed charges,Pays at 82.5% of total Billed charges,686.2,73,,548.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,658,70,,526.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.39,19.19,,144.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,470,50,,376,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.39,775.5,
PODIATRY - COUNTERSINK 2.5,10087158,CDM,272,RC,,,Outpatient,,,970,970,,,,,,Other,Not Separately Reimbursable,800.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,800.25,82.5,,640.2,percent of total billed charges,Pays at 82.5% of total Billed charges,708.1,73,,566.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,679,70,,543.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.14,19.19,,148.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,485,50,,388,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.14,800.25,
PODIATRY - SCREW 2.5 X 14MM LONG THREAD,10087159,CDM,272,RC,,,Outpatient,,,940,940,,,,,,Other,Not Separately Reimbursable,775.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,775.5,82.5,,620.4,percent of total billed charges,Pays at 82.5% of total Billed charges,686.2,73,,548.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,658,70,,526.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.39,19.19,,144.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,470,50,,376,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.39,775.5,
PODIATRY - SCREW 2.5 X30MM ST,10087166,CDM,272,RC,,,Outpatient,,,940,940,,,,,,Other,Not Separately Reimbursable,775.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,775.5,82.5,,620.4,percent of total billed charges,Pays at 82.5% of total Billed charges,686.2,73,,548.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,658,70,,526.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.39,19.19,,144.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,470,50,,376,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.39,775.5,
PODIATRY - WIRE GUIDE 1.4MM,10087167,CDM,272,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
PODIATRY - COUNTERSINK 3.8,10087168,CDM,272,RC,,,Outpatient,,,970,970,,,,,,Other,Not Separately Reimbursable,800.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,800.25,82.5,,640.2,percent of total billed charges,Pays at 82.5% of total Billed charges,708.1,73,,566.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,679,70,,543.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.14,19.19,,148.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,485,50,,388,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.14,800.25,
PODIATRY - SCREW 3.8 X 40MM,10087169,CDM,272,RC,,,Outpatient,,,940,940,,,,,,Other,Not Separately Reimbursable,775.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,775.5,82.5,,620.4,percent of total billed charges,Pays at 82.5% of total Billed charges,686.2,73,,548.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,658,70,,526.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.39,19.19,,144.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,470,50,,376,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.39,775.5,
PODIATRY - SCREW 2.5 X 20MM,10087171,CDM,272,RC,,,Outpatient,,,940,940,,,,,,Other,Not Separately Reimbursable,775.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,775.5,82.5,,620.4,percent of total billed charges,Pays at 82.5% of total Billed charges,686.2,73,,548.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,658,70,,526.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.39,19.19,,144.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,470,50,,376,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.39,775.5,
PODIATRY - SCREW 2.5 X 18MM,10087172,CDM,272,RC,,,Outpatient,,,940,940,,,,,,Other,Not Separately Reimbursable,775.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,775.5,82.5,,620.4,percent of total billed charges,Pays at 82.5% of total Billed charges,686.2,73,,548.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,658,70,,526.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.39,19.19,,144.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,470,50,,376,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.39,775.5,
PODIATRY - SCREW 4.0X26MM HIGH TORQUE C,10087176,CDM,272,RC,,,Outpatient,,,1160,1160,,,,,,Other,Not Separately Reimbursable,957,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,957,82.5,,765.6,percent of total billed charges,Pays at 82.5% of total Billed charges,846.8,73,,677.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,812,70,,649.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,222.6,19.19,,178.08,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,580,50,,464,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,222.6,957,
PODIATRY - SCREW 4.0X40MM HIGH TORQUE C,10087177,CDM,272,RC,,,Outpatient,,,1160,1160,,,,,,Other,Not Separately Reimbursable,957,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,957,82.5,,765.6,percent of total billed charges,Pays at 82.5% of total Billed charges,846.8,73,,677.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,812,70,,649.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,222.6,19.19,,178.08,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,580,50,,464,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,222.6,957,
PODIATRY - DRILL BIT 2.8MM,10087178,CDM,272,RC,,,Outpatient,,,910,910,,,,,,Other,Not Separately Reimbursable,750.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,750.75,82.5,,600.6,percent of total billed charges,Pays at 82.5% of total Billed charges,664.3,73,,531.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,637,70,,509.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.63,19.19,,139.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,455,50,,364,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.63,750.75,
PODIATRY - GUIDE WIRE 1.6MM,10087179,CDM,272,RC,,,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,165,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,165,82.5,,132,percent of total billed charges,Pays at 82.5% of total Billed charges,146,73,,116.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,70,,112,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,19.19,,30.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100,50,,80,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,165,
PODIATRY - FLEX TOE IMPLANT GREAT,10087180,CDM,272,RC,,,Outpatient,,,4840,4840,,,,,,Other,Not Separately Reimbursable,3993,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3993,82.5,,3194.4,percent of total billed charges,Pays at 82.5% of total Billed charges,3533.2,73,,2826.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3388,70,,2710.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,928.8,19.19,,743.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2420,50,,1936,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,928.8,3993,
PODIATRY - PLATE 4 HOLE 2OMM,10087181,CDM,272,RC,,,Outpatient,,,6910,6910,,,,,,Other,Not Separately Reimbursable,5700.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5700.75,82.5,,4560.6,percent of total billed charges,Pays at 82.5% of total Billed charges,5044.3,73,,4035.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4837,70,,3869.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1326.03,19.19,,1060.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3455,50,,2764,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1326.03,5700.75,
PODIATRY - SCREW 3.5MM 26MM,10087182,CDM,272,RC,,,Outpatient,,,1070,1070,,,,,,Other,Not Separately Reimbursable,882.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,882.75,82.5,,706.2,percent of total billed charges,Pays at 82.5% of total Billed charges,781.1,73,,624.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,749,70,,599.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205.33,19.19,,164.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,535,50,,428,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205.33,882.75,
PODIATRY - SCREW 3.5MM 24MM,10087183,CDM,272,RC,,,Outpatient,,,1070,1070,,,,,,Other,Not Separately Reimbursable,882.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,882.75,82.5,,706.2,percent of total billed charges,Pays at 82.5% of total Billed charges,781.1,73,,624.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,749,70,,599.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205.33,19.19,,164.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,535,50,,428,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205.33,882.75,
PODIATRY - DRILL BIT 2.8MM,10087184,CDM,272,RC,,,Outpatient,,,800,800,,,,,,Other,Not Separately Reimbursable,660,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,660,82.5,,528,percent of total billed charges,Pays at 82.5% of total Billed charges,584,73,,467.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,560,70,,448,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153.52,19.19,,122.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,400,50,,320,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153.52,660,
PODIATRY - PLATE TACK,10087185,CDM,272,RC,,,Outpatient,,,670,670,,,,,,Other,Not Separately Reimbursable,552.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,552.75,82.5,,442.2,percent of total billed charges,Pays at 82.5% of total Billed charges,489.1,73,,391.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,469,70,,375.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.57,19.19,,102.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,335,50,,268,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.57,552.75,
PODIATRY - PLATE FIB 9 HOLE,10087189,CDM,272,RC,,,Outpatient,,,5620,5620,,,,,,Other,Not Separately Reimbursable,4636.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4636.5,82.5,,3709.2,percent of total billed charges,Pays at 82.5% of total Billed charges,4102.6,73,,3282.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3934,70,,3147.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1078.48,19.19,,862.784,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2810,50,,2248,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1078.48,4636.5,
PODIATRY - SCREW 3.5 NL 22MM,10087190,CDM,272,RC,,,Outpatient,,,870,870,,,,,,Other,Not Separately Reimbursable,717.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,717.75,82.5,,574.2,percent of total billed charges,Pays at 82.5% of total Billed charges,635.1,73,,508.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,609,70,,487.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.95,19.19,,133.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,435,50,,348,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.95,717.75,
PODIATRY - SCREW 3.5 NL 16MM,10087191,CDM,272,RC,,,Outpatient,,,870,870,,,,,,Other,Not Separately Reimbursable,717.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,717.75,82.5,,574.2,percent of total billed charges,Pays at 82.5% of total Billed charges,635.1,73,,508.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,609,70,,487.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.95,19.19,,133.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,435,50,,348,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.95,717.75,
PODIATRY - SCREW 3.5 NL 12MM,10087192,CDM,272,RC,,,Outpatient,,,840,840,,,,,,Other,Not Separately Reimbursable,693,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,693,82.5,,554.4,percent of total billed charges,Pays at 82.5% of total Billed charges,613.2,73,,490.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,588,70,,470.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,19.19,,128.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,420,50,,336,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,693,
PODIATRY - SCREW 3.5 NL 14MM,10087193,CDM,272,RC,,,Outpatient,,,840,840,,,,,,Other,Not Separately Reimbursable,693,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,693,82.5,,554.4,percent of total billed charges,Pays at 82.5% of total Billed charges,613.2,73,,490.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,588,70,,470.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,19.19,,128.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,420,50,,336,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,693,
PODIATRY - SCREW 3.5 NL 16MM,10087194,CDM,272,RC,,,Outpatient,,,840,840,,,,,,Other,Not Separately Reimbursable,693,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,693,82.5,,554.4,percent of total billed charges,Pays at 82.5% of total Billed charges,613.2,73,,490.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,588,70,,470.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,19.19,,128.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,420,50,,336,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,693,
PODIATRY - SCREW 3.5 NL 18MM,10087195,CDM,272,RC,,,Outpatient,,,840,840,,,,,,Other,Not Separately Reimbursable,693,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,693,82.5,,554.4,percent of total billed charges,Pays at 82.5% of total Billed charges,613.2,73,,490.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,588,70,,470.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,19.19,,128.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,420,50,,336,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,693,
NEUROSTIMULATOR,10087196,CDM,272,RC,,,Outpatient,,,840,840,,,,,,Other,Not Separately Reimbursable,693,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,693,82.5,,554.4,percent of total billed charges,Pays at 82.5% of total Billed charges,613.2,73,,490.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,588,70,,470.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,19.19,,128.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,420,50,,336,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.2,693,
PATIENT PROGRAMMER,10087197,CDM,272,RC,,,Outpatient,,,2980,2980,,,,,,Other,Not Separately Reimbursable,2458.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2458.5,82.5,,1966.8,percent of total billed charges,Pays at 82.5% of total Billed charges,2175.4,73,,1740.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2086,70,,1668.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,571.86,19.19,,457.488,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1490,50,,1192,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,571.86,2458.5,
ANTENNA,10087198,CDM,272,RC,,,Outpatient,,,330,330,,,,,,Other,Not Separately Reimbursable,272.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,272.25,82.5,,217.8,percent of total billed charges,Pays at 82.5% of total Billed charges,240.9,73,,192.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,231,70,,184.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.33,19.19,,50.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165,50,,132,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.33,272.25,
PODIATRY - SCREW 3.8 X 50MM,10087219,CDM,272,RC,,,Outpatient,,,940,940,,,,,,Other,Not Separately Reimbursable,775.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,775.5,82.5,,620.4,percent of total billed charges,Pays at 82.5% of total Billed charges,686.2,73,,548.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,658,70,,526.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.39,19.19,,144.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,470,50,,376,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.39,775.5,
PODIATRY - 1.4 K WIRE,10087220,CDM,272,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
PODIATRY - 20M 4H T PLATE,10087234,CDM,271,RC,,,Outpatient,,,790,790,,,,,,Other,Not Separately Reimbursable,651.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,651.75,82.5,,521.4,percent of total billed charges,Pays at 82.5% of total Billed charges,576.7,73,,461.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,553,70,,442.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.6,19.19,,121.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,395,50,,316,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.6,651.75,
SUCTION POLYP SNARE TRAP,10087255,CDM,272,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
CATHETER TRAY W/O CATH,10087275,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
FOLEY CATHETER TRAY 14FR,10087276,CDM,272,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
FOLEY CATHETER TRAY 16FR,10087277,CDM,272,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
FOLEY CATHETER TRAY 18FR,10087278,CDM,272,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
FC TRAY 16 FR W/URINE MTR,10087279,CDM,272,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
ORAL CARE KIT,10087280,CDM,272,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ORAL CARE KIT - SUCTION VENT,10087281,CDM,272,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
TRAY CATHETER (STRAIGHT) 15FR,10087284,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
RECTAL TUBE KIT DIGNISHIELD,10087299,CDM,272,RC,,,Outpatient,,,520,520,,,,,,Other,Not Separately Reimbursable,429,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,429,82.5,,343.2,percent of total billed charges,Pays at 82.5% of total Billed charges,379.6,73,,303.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,364,70,,291.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.79,19.19,,79.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,260,50,,208,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.79,429,
URINE METER - STERILE,10087300,CDM,270,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
URINARY LEG BAG,10087301,CDM,271,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
RECTAL TUBE REPLACEMENT BAG DIGNISHIELD,10087302,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
BIOPSY FORCEP HOT,10087525,CDM,272,RC,,,Outpatient,,,440,440,,,,,,Other,Not Separately Reimbursable,363,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,363,82.5,,290.4,percent of total billed charges,Pays at 82.5% of total Billed charges,321.2,73,,256.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,308,70,,246.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.44,19.19,,67.552,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,220,50,,176,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.44,363,
SUCTION YANKAUER INST,10088100,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SUCTION YANKAUER PEDI,10088101,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SPONGE TONSIL - PKG,10088111,CDM,270,RC,,,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,9.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.08,82.5,,7.264,percent of total billed charges,Pays at 82.5% of total Billed charges,8.03,73,,6.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.7,70,,6.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,19.19,,1.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.5,50,,4.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,9.08,
PERCUT INTRODUCER SYS 8FR,10088164,CDM,272,RC,,,Outpatient,,,220,220,,,,,,Other,Not Separately Reimbursable,181.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,181.5,82.5,,145.2,percent of total billed charges,Pays at 82.5% of total Billed charges,160.6,73,,128.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154,70,,123.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,19.19,,33.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110,50,,88,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,181.5,
TRAY LUMBAR PUNCTURE ADULT,10088172,CDM,272,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
TRAY LUMBAR PUNCTURE PEDIATRIC,10088173,CDM,272,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
TRAY INCISION & DRAINAGE,10088176,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
TRAY DRESSING CHG Central Line,10088177,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
STAT-LOCK PICC PLUS STABILIZATION DEVICE,10088190,CDM,272,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DRAPE - IOBAN 13X13,10088193,CDM,270,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
DRAPE - IOBAN 6X8,10088197,CDM,270,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DRAPE - IOBAN 24x24,10088198,CDM,270,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
CATHETER TRAY W/CATHETER,10088204,CDM,272,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ULTRASONIC DISSECTOR - CORDLESS,10088214,CDM,272,RC,,,Outpatient,,,2210,2210,,,,,,Other,Not Separately Reimbursable,1823.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1823.25,82.5,,1458.6,percent of total billed charges,Pays at 82.5% of total Billed charges,1613.3,73,,1290.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1547,70,,1237.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,424.1,19.19,,339.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1105,50,,884,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,424.1,1823.25,
TROCAR CATH 20FR,10088227,CDM,272,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
MUCOS SPECIMAN TRAP,10088230,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
BRONCH - MUCOS SPECIMAN TRAP,10088231,CDM,270,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
BLADE MCGRATH MAC SIZE 2 LARYNGOSCOPE,10088247,CDM,272,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
BLADE MCGRATH MAC SIZE 4 LARYNGOSCOPE,10088248,CDM,272,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
TROCAR - 5MM (B5LT),10088253,CDM,272,RC,,,Outpatient,,,640,640,,,,,,Other,Not Separately Reimbursable,528,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,528,82.5,,422.4,percent of total billed charges,Pays at 82.5% of total Billed charges,467.2,73,,373.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,448,70,,358.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.82,19.19,,98.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,320,50,,256,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.82,528,
TROCAR - 5MM DILATING TIP (D5LT),10088255,CDM,272,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
TROCAR - 11MM DILATING TIP (D11LT),10088256,CDM,272,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
TROCAR - 12MM BLADELESS (B12LP),10088257,CDM,272,RC,,,Outpatient,,,250,250,,,,,,Other,Not Separately Reimbursable,206.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,206.25,82.5,,165,percent of total billed charges,Pays at 82.5% of total Billed charges,182.5,73,,146,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,70,,140,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,19.19,,38.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125,50,,100,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,206.25,
CANNULA 6.5 DRI-LOK,10088260,CDM,272,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
CANNULA 8.0 DRI-LOK,10088261,CDM,272,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
CATH HEMODIALYSIS 27CM,10088269,CDM,272,RC,,,Outpatient,,,740,740,,,,,,Other,Not Separately Reimbursable,610.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,610.5,82.5,,488.4,percent of total billed charges,Pays at 82.5% of total Billed charges,540.2,73,,432.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,518,70,,414.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,142.01,19.19,,113.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,370,50,,296,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,142.01,610.5,
TROCAR CATH 28FR,10088270,CDM,272,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
CATH HEMODIALYSIS 15X9.5,10088271,CDM,272,RC,,,Outpatient,,,1080,1080,,,,,,Other,Not Separately Reimbursable,891,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,891,82.5,,712.8,percent of total billed charges,Pays at 82.5% of total Billed charges,788.4,73,,630.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,756,70,,604.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,207.25,19.19,,165.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,540,50,,432,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,207.25,891,
CATH HEMODIALYSIS 15X11,10088272,CDM,272,RC,,,Outpatient,,,1080,1080,,,,,,Other,Not Separately Reimbursable,891,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,891,82.5,,712.8,percent of total billed charges,Pays at 82.5% of total Billed charges,788.4,73,,630.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,756,70,,604.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,207.25,19.19,,165.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,540,50,,432,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,207.25,891,
CATH HEMODIALYSIS 23CM,10088273,CDM,272,RC,,,Outpatient,,,650,650,,,,,,Other,Not Separately Reimbursable,536.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,536.25,82.5,,429,percent of total billed charges,Pays at 82.5% of total Billed charges,474.5,73,,379.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,455,70,,364,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124.74,19.19,,99.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,325,50,,260,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124.74,536.25,
CATH HEMODIALYSIS 31CM,10088274,CDM,272,RC,,,Outpatient,,,740,740,,,,,,Other,Not Separately Reimbursable,610.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,610.5,82.5,,488.4,percent of total billed charges,Pays at 82.5% of total Billed charges,540.2,73,,432.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,518,70,,414.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,142.01,19.19,,113.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,370,50,,296,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,142.01,610.5,
CATH GROSHONG CV,10088275,CDM,272,RC,,,Outpatient,,,900,900,,,,,,Other,Not Separately Reimbursable,742.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,742.5,82.5,,594,percent of total billed charges,Pays at 82.5% of total Billed charges,657,73,,525.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,630,70,,504,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,172.71,19.19,,138.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,450,50,,360,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,172.71,742.5,
TROCAR - 12MM BLUNT TIP (H12LP),10088276,CDM,272,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
CATH HEMODIALYSIS 32CM,10088277,CDM,272,RC,,,Outpatient,,,640,640,,,,,,Other,Not Separately Reimbursable,528,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,528,82.5,,422.4,percent of total billed charges,Pays at 82.5% of total Billed charges,467.2,73,,373.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,448,70,,358.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.82,19.19,,98.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,320,50,,256,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.82,528,
CATHETHER EPIDURAL (SHORES) 19GA,10088278,CDM,272,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
CATHETHER EPIDURAL TUN-L-XL,10088279,CDM,272,RC,,,Outpatient,,,370,370,,,,,,Other,Not Separately Reimbursable,305.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,305.25,82.5,,244.2,percent of total billed charges,Pays at 82.5% of total Billed charges,270.1,73,,216.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,259,70,,207.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,19.19,,56.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,185,50,,148,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,305.25,
CATH GROSHONG CV 9.5 DUO,10088282,CDM,272,RC,,,Outpatient,,,1550,1550,,,,,,Other,Not Separately Reimbursable,1278.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1278.75,82.5,,1023,percent of total billed charges,Pays at 82.5% of total Billed charges,1131.5,73,,905.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1085,70,,868,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,297.45,19.19,,237.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,775,50,,620,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,297.45,1278.75,
CATH DIALYSIS 12FR TEMP,10088285,CDM,272,RC,,,Outpatient,,,480,480,,,,,,Other,Not Separately Reimbursable,396,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,396,82.5,,316.8,percent of total billed charges,Pays at 82.5% of total Billed charges,350.4,73,,280.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,336,70,,268.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.11,19.19,,73.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,240,50,,192,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.11,396,
CATH DIALYSIS KIT,10088286,CDM,272,RC,,,Outpatient,,,480,480,,,,,,Other,Not Separately Reimbursable,396,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,396,82.5,,316.8,percent of total billed charges,Pays at 82.5% of total Billed charges,350.4,73,,280.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,336,70,,268.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.11,19.19,,73.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,240,50,,192,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.11,396,
CATH HEMO 4fr INTRODUCER,10088299,CDM,272,RC,,,Outpatient,,,210,210,,,,,,Other,Not Separately Reimbursable,173.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,173.25,82.5,,138.6,percent of total billed charges,Pays at 82.5% of total Billed charges,153.3,73,,122.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,70,,117.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,19.19,,32.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,50,,84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,173.25,
WARMING BLANKET,10088305,CDM,271,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
SPLINT PLASTER 5,10088556,CDM,271,RC,,,Outpatient,,,330,330,,,,,,Other,Not Separately Reimbursable,272.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,272.25,82.5,,217.8,percent of total billed charges,Pays at 82.5% of total Billed charges,240.9,73,,192.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,231,70,,184.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.33,19.19,,50.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165,50,,132,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.33,272.25,
VISCOAT,10088606,CDM,271,RC,,,Outpatient,,,600,600,,,,,,Other,Not Separately Reimbursable,495,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,495,82.5,,396,percent of total billed charges,Pays at 82.5% of total Billed charges,438,73,,350.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,420,70,,336,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.14,19.19,,92.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,300,50,,240,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.14,495,
MIOSTAT INTRAOCULAR SOL 1.5ML,10088608,CDM,271,RC,,,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
MECONIUM ASPIRATOR,10088625,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
INTRA OSSCEOUS CATH 18FR,10088628,CDM,272,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
INTRA OSSCEOUS CATH 15FR,10088629,CDM,272,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
INSUFFLATION TUBING (LAP) ARTHREX,10088645,CDM,272,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
BLADE MED NARROW (STRYKER),10088667,CDM,272,RC,,,Outpatient,,,170,170,,,,,,Other,Not Separately Reimbursable,140.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,140.25,82.5,,112.2,percent of total billed charges,Pays at 82.5% of total Billed charges,124.1,73,,99.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,119,70,,95.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.62,19.19,,26.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85,50,,68,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.62,140.25,
GORTEX MESH 10cm X 12cm,10088680,CDM,278,RC,,,Outpatient,,,1410,1410,,,,,,Other,Not Separately Reimbursable,1410,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1410,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1029.3,73,,823.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,987,70,,789.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,270.58,19.19,,216.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,705,50,,564,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,270.58,1410,
SUPRAFOIL 4X4 .040,10088755,CDM,272,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
SUPRAFOIL 4X4 .06MM,10088756,CDM,272,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
BIPOLAR BRUSH STRAIGHT 18GA,10088837,CDM,272,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
ENDO CLIP 5MM (SMALL),10089023,CDM,272,RC,,,Outpatient,,,600,600,,,,,,Other,Not Separately Reimbursable,495,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,495,82.5,,396,percent of total billed charges,Pays at 82.5% of total Billed charges,438,73,,350.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,420,70,,336,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.14,19.19,,92.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,300,50,,240,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.14,495,
ENDO CLIP 10MM (LARGE),10089024,CDM,272,RC,,,Outpatient,,,790,790,,,,,,Other,Not Separately Reimbursable,651.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,651.75,82.5,,521.4,percent of total billed charges,Pays at 82.5% of total Billed charges,576.7,73,,461.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,553,70,,442.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.6,19.19,,121.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,395,50,,316,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.6,651.75,
ENDO LOOP VICRYL 0 18,10089025,CDM,272,RC,,,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
ENDO CLOSE,10089026,CDM,272,RC,,,Outpatient,,,290,290,,,,,,Other,Not Separately Reimbursable,239.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,239.25,82.5,,191.4,percent of total billed charges,Pays at 82.5% of total Billed charges,211.7,73,,169.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203,70,,162.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.65,19.19,,44.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,145,50,,116,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.65,239.25,
ORTHO BARRELL BUR,10089126,CDM,271,RC,,,Outpatient,,,850,850,,,,,,Other,Not Separately Reimbursable,701.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,701.25,82.5,,561,percent of total billed charges,Pays at 82.5% of total Billed charges,620.5,73,,496.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595,70,,476,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.12,19.19,,130.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,425,50,,340,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.12,701.25,
ORTHO RF 2 PROBES 90S,10089127,CDM,271,RC,,,Outpatient,,,500,500,,,,,,Other,Not Separately Reimbursable,412.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,412.5,82.5,,330,percent of total billed charges,Pays at 82.5% of total Billed charges,365,73,,292,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,350,70,,280,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.95,19.19,,76.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,250,50,,200,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.95,412.5,
BARD MRI PORT SMALL,10089400,CDM,272,RC,,,Outpatient,,,1460,1460,,,,,,Other,Not Separately Reimbursable,1204.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1204.5,82.5,,963.6,percent of total billed charges,Pays at 82.5% of total Billed charges,1065.8,73,,852.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1022,70,,817.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280.17,19.19,,224.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,730,50,,584,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280.17,1204.5,
BARD MRI PORT LARGE,10089401,CDM,272,RC,,,Outpatient,,,2050,2050,,,,,,Other,Not Separately Reimbursable,1691.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1691.25,82.5,,1353,percent of total billed charges,Pays at 82.5% of total Billed charges,1496.5,73,,1197.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1435,70,,1148,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,393.4,19.19,,314.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1025,50,,820,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,393.4,1691.25,
BARD MRI PORT SINGLE LUMEN,10089402,CDM,272,RC,,,Outpatient,,,870,870,,,,,,Other,Not Separately Reimbursable,717.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,717.75,82.5,,574.2,percent of total billed charges,Pays at 82.5% of total Billed charges,635.1,73,,508.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,609,70,,487.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.95,19.19,,133.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,435,50,,348,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.95,717.75,
ENDO POUCH / CATCH 10MM,10089429,CDM,271,RC,,,Outpatient,,,210,210,,,,,,Other,Not Separately Reimbursable,173.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,173.25,82.5,,138.6,percent of total billed charges,Pays at 82.5% of total Billed charges,153.3,73,,122.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,70,,117.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,19.19,,32.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,50,,84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,173.25,
MAMMO 10G PREC NEEDLE (BIOPSY),10089450,CDM,272,RC,,,Outpatient,,,1280,1280,,,,,,Other,Not Separately Reimbursable,1056,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1056,82.5,,844.8,percent of total billed charges,Pays at 82.5% of total Billed charges,934.4,73,,747.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,896,70,,716.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245.63,19.19,,196.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,640,50,,512,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245.63,1056,
MAMMO 14G PREC NEEDLE (BIOPSY),10089451,CDM,272,RC,,,Outpatient,,,890,890,,,,,,Other,Not Separately Reimbursable,734.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,734.25,82.5,,587.4,percent of total billed charges,Pays at 82.5% of total Billed charges,649.7,73,,519.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,623,70,,498.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,19.19,,136.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,445,50,,356,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,734.25,
MAMMO BIOPSY INSTRUMENT,10089452,CDM,272,RC,,,Outpatient,,,330,330,,,,,,Other,Not Separately Reimbursable,272.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,272.25,82.5,,217.8,percent of total billed charges,Pays at 82.5% of total Billed charges,240.9,73,,192.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,231,70,,184.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.33,19.19,,50.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165,50,,132,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.33,272.25,
MAMMO ULTRACLIP MARKER,10089453,CDM,272,RC,,,Outpatient,,,770,770,,,,,,Other,Not Separately Reimbursable,635.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,635.25,82.5,,508.2,percent of total billed charges,Pays at 82.5% of total Billed charges,562.1,73,,449.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,539,70,,431.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147.76,19.19,,118.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,385,50,,308,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147.76,635.25,
MAMMO KOPANS NDL 20G 5CM,10089454,CDM,272,RC,,,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,165,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,165,82.5,,132,percent of total billed charges,Pays at 82.5% of total Billed charges,146,73,,116.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,70,,112,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,19.19,,30.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100,50,,80,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,165,
MAMMO KOPANS NDL 20G 9CM,10089455,CDM,272,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
PAIN - LINEAR ST TRIAL LEAD KIT 50CM,10089702,CDM,272,RC,,,Outpatient,,,4540,4540,,,,,,Other,Not Separately Reimbursable,3745.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3745.5,82.5,,2996.4,percent of total billed charges,Pays at 82.5% of total Billed charges,3314.2,73,,2651.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3178,70,,2542.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,871.23,19.19,,696.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2270,50,,1816,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,871.23,3745.5,
PAIN - NEEDLE 5 INSERTION,10089703,CDM,272,RC,,,Outpatient,,,870,870,,,,,,Other,Not Separately Reimbursable,717.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,717.75,82.5,,574.2,percent of total billed charges,Pays at 82.5% of total Billed charges,635.1,73,,508.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,609,70,,487.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.95,19.19,,133.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,435,50,,348,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.95,717.75,
PAIN - OR CABLE EXTENTION 2X8,10089704,CDM,272,RC,,,Outpatient,,,1810,1810,,,,,,Other,Not Separately Reimbursable,1493.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1493.25,82.5,,1194.6,percent of total billed charges,Pays at 82.5% of total Billed charges,1321.3,73,,1057.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1267,70,,1013.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,347.34,19.19,,277.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,905,50,,724,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,347.34,1493.25,
KIT MONTAGE PATIENT TRIAL US,10089705,CDM,272,RC,,,Outpatient,,,470,470,,,,,,Other,Not Separately Reimbursable,387.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,387.75,82.5,,310.2,percent of total billed charges,Pays at 82.5% of total Billed charges,343.1,73,,274.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329,70,,263.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,19.19,,72.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,235,50,,188,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,387.75,
KUGEL CIRCLE LARGE (4.5 X 4.5 ) VENTRIO,10089766,CDM,272,RC,,,Outpatient,,,2730,2730,,,,,,Other,Not Separately Reimbursable,2252.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2252.25,82.5,,1801.8,percent of total billed charges,Pays at 82.5% of total Billed charges,1992.9,73,,1594.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1911,70,,1528.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,523.89,19.19,,419.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1365,50,,1092,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,523.89,2252.25,
KUGEL CIRCLE SMALL (3 X 3 ) VENTRIO,10089767,CDM,271,RC,,,Outpatient,,,1970,1970,,,,,,Other,Not Separately Reimbursable,1625.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1625.25,82.5,,1300.2,percent of total billed charges,Pays at 82.5% of total Billed charges,1438.1,73,,1150.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1379,70,,1103.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,378.04,19.19,,302.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,985,50,,788,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,378.04,1625.25,
KUGEL OVAL LARGE (5.4 X 7 ) COMPOSIX,10089768,CDM,271,RC,,,Outpatient,,,3750,3750,,,,,,Other,Not Separately Reimbursable,3093.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3093.75,82.5,,2475,percent of total billed charges,Pays at 82.5% of total Billed charges,2737.5,73,,2190,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2625,70,,2100,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,719.63,19.19,,575.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1875,50,,1500,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,719.63,3093.75,
KUGEL OVAL MEDIUM (4.3X5.5) VENTRIO,10089769,CDM,271,RC,,,Outpatient,,,2750,2750,,,,,,Other,Not Separately Reimbursable,2268.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2268.75,82.5,,1815,percent of total billed charges,Pays at 82.5% of total Billed charges,2007.5,73,,1606,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1925,70,,1540,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,527.73,19.19,,422.184,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1375,50,,1100,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,527.73,2268.75,
MESH KEYHOLE 10CM X 4.5CM,10089770,CDM,278,RC,,,Outpatient,,,440,440,,,,,,Other,Not Separately Reimbursable,440,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,440,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,321.2,73,,256.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,308,70,,246.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.44,19.19,,67.552,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,220,50,,176,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.44,440,
DULEX PATCH (BARD)GE,10089771,CDM,272,RC,,,Outpatient,,,2880,2880,,,,,,Other,Not Separately Reimbursable,2376,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2376,82.5,,1900.8,percent of total billed charges,Pays at 82.5% of total Billed charges,2102.4,73,,1681.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2016,70,,1612.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,552.67,19.19,,442.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1440,50,,1152,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,552.67,2376,
KUGEL OVAL SMALL (3 X 4.6 ),10089772,CDM,271,RC,,,Outpatient,,,1730,1730,,,,,,Other,Not Separately Reimbursable,1427.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1427.25,82.5,,1141.8,percent of total billed charges,Pays at 82.5% of total Billed charges,1262.9,73,,1010.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1211,70,,968.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,331.99,19.19,,265.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,865,50,,692,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,331.99,1427.25,
KUGEL OVAL XLG (10.8 X 13.7 ) COMPOSIX,10089775,CDM,271,RC,,,Outpatient,,,5420,5420,,,,,,Other,Not Separately Reimbursable,4471.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4471.5,82.5,,3577.2,percent of total billed charges,Pays at 82.5% of total Billed charges,3956.6,73,,3165.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3794,70,,3035.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1040.1,19.19,,832.08,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2710,50,,2168,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1040.1,4471.5,
KUGEL OVAL XLG (8.7 X 10.7 ) COMPOSIX,10089776,CDM,271,RC,,,Outpatient,,,4340,4340,,,,,,Other,Not Separately Reimbursable,3580.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3580.5,82.5,,2864.4,percent of total billed charges,Pays at 82.5% of total Billed charges,3168.2,73,,2534.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3038,70,,2430.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,832.85,19.19,,666.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2170,50,,1736,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,832.85,3580.5,
KUGEL OVAL LARGE (7.7 X 9.7 ) VENTRIO,10089777,CDM,278,RC,,,Outpatient,,,3250,3250,,,,,,Other,Not Separately Reimbursable,3250,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,3250,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2372.5,73,,1898,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2275,70,,1820,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,623.68,19.19,,498.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1625,50,,1300,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,623.68,3250,
KUGEL OVAL SMALL (3.1 X 4.7 ) COMPOSIX,10089778,CDM,278,RC,,,Outpatient,,,2400,2400,,,,,,Other,Not Separately Reimbursable,2400,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2400,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1752,73,,1401.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1680,70,,1344,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,460.56,19.19,,368.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1200,50,,960,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,460.56,2400,
MESH 6X13CM OVALE FENTE,10089780,CDM,271,RC,,,Outpatient,,,1550,1550,,,,,,Other,Not Separately Reimbursable,1278.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1278.75,82.5,,1023,percent of total billed charges,Pays at 82.5% of total Billed charges,1131.5,73,,905.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1085,70,,868,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,297.45,19.19,,237.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,775,50,,620,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,297.45,1278.75,
MESH THE FLAP SURIMESH,10089781,CDM,271,RC,,,Outpatient,,,1640,1640,,,,,,Other,Not Separately Reimbursable,1353,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1353,82.5,,1082.4,percent of total billed charges,Pays at 82.5% of total Billed charges,1197.2,73,,957.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1148,70,,918.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,314.72,19.19,,251.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,820,50,,656,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,314.72,1353,
MESH 10CM ROUND,10089782,CDM,271,RC,,,Outpatient,,,2710,2710,,,,,,Other,Not Separately Reimbursable,2235.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2235.75,82.5,,1788.6,percent of total billed charges,Pays at 82.5% of total Billed charges,1978.3,73,,1582.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1897,70,,1517.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,520.05,19.19,,416.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1355,50,,1084,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,520.05,2235.75,
MESH FLAT SHEET 10X15CM,10089783,CDM,271,RC,,,Outpatient,,,1220,1220,,,,,,Other,Not Separately Reimbursable,1006.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1006.5,82.5,,805.2,percent of total billed charges,Pays at 82.5% of total Billed charges,890.6,73,,712.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,854,70,,683.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,234.12,19.19,,187.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,610,50,,488,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,234.12,1006.5,
KUGEL OVAL (3.1 X 4.7) VENTRIO,10089785,CDM,271,RC,,,Outpatient,,,2240,2240,,,,,,Other,Not Separately Reimbursable,1848,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1848,82.5,,1478.4,percent of total billed charges,Pays at 82.5% of total Billed charges,1635.2,73,,1308.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1568,70,,1254.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,429.86,19.19,,343.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1120,50,,896,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,429.86,1848,
KUGEL OVAL X-LARGE (8.7 X10.7 ) VENTRIO,10089786,CDM,271,RC,,,Outpatient,,,5100,5100,,,,,,Other,Not Separately Reimbursable,4207.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4207.5,82.5,,3366,percent of total billed charges,Pays at 82.5% of total Billed charges,3723,73,,2978.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3570,70,,2856,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,978.69,19.19,,782.952,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2550,50,,2040,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,978.69,4207.5,
KUGEL OVAL LARGE (6.1 X10.1 ) VENTRIO,10089787,CDM,278,RC,,,Outpatient,,,5710,5710,,,,,,Other,Not Separately Reimbursable,5710,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,5710,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,4168.3,73,,3334.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3997,70,,3197.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1095.75,19.19,,876.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2855,50,,2284,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1095.75,5710,
NEGATIVE PRESSURE PICO 4X8 (SINGLE USE),10089950,CDM,272,RC,,,Outpatient,,,900,900,,,,,,Other,Not Separately Reimbursable,742.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,742.5,82.5,,594,percent of total billed charges,Pays at 82.5% of total Billed charges,657,73,,525.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,630,70,,504,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,172.71,19.19,,138.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,450,50,,360,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,172.71,742.5,
NEGATIVE PRESSURE PICO 6X6 (SINGLE USE),10089951,CDM,272,RC,,,Outpatient,,,900,900,,,,,,Other,Not Separately Reimbursable,742.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,742.5,82.5,,594,percent of total billed charges,Pays at 82.5% of total Billed charges,657,73,,525.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,630,70,,504,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,172.71,19.19,,138.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,450,50,,360,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,172.71,742.5,
GROUNDING PAD PEDIATRIC,10089974,CDM,270,RC,A6533,HCPCS,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
T E D THIGH XLG/REG,10096944,CDM,271,RC,99156,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
M-SEDATION PHY/OTH THN PRFMG 5 + YRS,10099156,CDM,370,RC,99157,HCPCS,Outpatient,,,268,268,,,,,,Other,Not Separately Reimbursable,221.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,221.1,82.5,,176.88,percent of total billed charges,Pays at 82.5% of total Billed charges,195.64,73,,156.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,187.6,70,,150.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.43,19.19,,41.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,134,50,,107.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.43,221.1,
M-SEDAJ PHY/OTH THN PRFMG EA 15 MIN,10099157,CDM,370,RC,G0008,HCPCS,Outpatient,,,134,134,,,,,,Other,Not Separately Reimbursable,110.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,110.55,82.5,,88.44,percent of total billed charges,Pays at 82.5% of total Billed charges,97.82,73,,78.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.8,70,,75.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.71,19.19,,20.568,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67,50,,53.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.71,110.55,
AMINISTRATION OF INFLUENZA VIRUS VACCINE,11010008,CDM,771,RC,G0009,HCPCS,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
AMINISTRATION OF PNEUMOCOCCAL VACCINE,11010009,CDM,771,RC,10061,HCPCS,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
I&D COMPLICATED OR MULTIPLE,11010061,CDM,450,RC,10081,HCPCS,Outpatient,,,410,410,,,,,,Other,Not Separately Reimbursable,338.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,338.25,82.5,,270.6,percent of total billed charges,Pays at 82.5% of total Billed charges,299.3,73,,239.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,287,70,,229.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,19.19,,62.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205,50,,164,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,338.25,
I&D OF PILONIDAL CYST;SIMPLE,11010081,CDM,450,RC,11042,HCPCS,Outpatient,,,1250,1250,,,,,,Other,Not Separately Reimbursable,1031.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1031.25,82.5,,825,percent of total billed charges,Pays at 82.5% of total Billed charges,912.5,73,,730,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,875,70,,700,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,239.88,19.19,,191.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,625,50,,500,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,239.88,1031.25,
DEBRIDEMENT OF SKIN & SUBCUT TISSUE,11011042,CDM,450,RC,11422,HCPCS,Outpatient,,,283,283,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,206.59,73,,165.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,198.1,70,,158.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.31,19.19,,43.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,141.5,50,,113.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.31,1319.85,
Under Excision-Benign Lesions Procedures on the Skin 1.1-2 CM,11011422,CDM,450,RC,11760,HCPCS,Outpatient,,,1910,1910,,,,,,Other,Not Separately Reimbursable,1575.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1575.75,82.5,,1260.6,percent of total billed charges,Pays at 82.5% of total Billed charges,1394.3,73,,1115.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1337,70,,1069.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,366.53,19.19,,293.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,955,50,,764,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,366.53,1575.75,
REPAIR OF BED NAIL,11011760,CDM,450,RC,12005,HCPCS,Outpatient,,,300,300,,,,,,Other,Not Separately Reimbursable,247.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,247.5,82.5,,198,percent of total billed charges,Pays at 82.5% of total Billed charges,219,73,,175.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,210,70,,168,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.57,19.19,,46.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,150,50,,120,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.57,247.5,
SMPL RPR SCALP/NECK/AX/GEN/TRUNK 12.6-20,11012005,CDM,450,RC,12006,HCPCS,Outpatient,,,222,222,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,162.06,73,,129.648,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.4,70,,124.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.6,19.19,,34.08,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111,50,,88.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.6,1319.85,
SMPL RPR SCALP/NECK/AX/GEN/TRUNK 20.1-30,11012006,CDM,450,RC,99281,HCPCS,Outpatient,,,932,932,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,680.36,73,,544.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,652.4,70,,521.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,178.85,19.19,,143.08,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,466,50,,372.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,178.85,1319.85,
ER VISIT; LEVEL I,11012100,CDM,450,RC,99282,HCPCS,Outpatient,,,215,215,,,,,,Other,Not Separately Reimbursable,177.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,177.38,82.5,,141.904,percent of total billed charges,Pays at 82.5% of total Billed charges,156.95,73,,125.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,150.5,70,,120.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.26,19.19,,33.008,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.5,50,,86,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.26,177.38,
ER VISIT; LEVEL II,11012105,CDM,450,RC,99283,HCPCS,Outpatient,,,405,405,,,,,,Other,Not Separately Reimbursable,334.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,334.13,82.5,,267.304,percent of total billed charges,Pays at 82.5% of total Billed charges,295.65,73,,236.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,283.5,70,,226.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.72,19.19,,62.176,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,202.5,50,,162,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.72,334.13,
"Emergency department visit, moderately severe problem",11012110,CDM,450,RC,99284,HCPCS,Outpatient,,,541,541,,,,,,Other,Not Separately Reimbursable,446.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,446.33,82.5,,357.064,percent of total billed charges,Pays at 82.5% of total Billed charges,394.93,73,,315.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,378.7,70,,302.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.82,19.19,,83.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,270.5,50,,216.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.82,446.33,
"Emergency department visit, problem of high severity",11012115,CDM,450,RC,99285,HCPCS,Outpatient,,,876,876,,,,,,Other,Not Separately Reimbursable,722.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,722.7,82.5,,578.16,percent of total billed charges,Pays at 82.5% of total Billed charges,639.48,73,,511.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,613.2,70,,490.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,168.1,19.19,,134.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,438,50,,350.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,168.1,722.7,
"Emergency department visit, problem with significant threat to life or function",11012120,CDM,450,RC,99291,HCPCS,Outpatient,,,1262,1262,,,,,,Other,Not Separately Reimbursable,1041.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1041.15,82.5,,832.92,percent of total billed charges,Pays at 82.5% of total Billed charges,921.26,73,,737.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,883.4,70,,706.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,242.18,19.19,,193.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,631,50,,504.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,242.18,1041.15,
"ER VISIT;CRITICAL, <74 MIN",11012127,CDM,450,RC,99281,HCPCS,Outpatient,,,1735,1735,,,,,,Other,Not Separately Reimbursable,1431.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1431.38,82.5,,1145.104,percent of total billed charges,Pays at 82.5% of total Billed charges,1266.55,73,,1013.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1214.5,70,,971.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,332.95,19.19,,266.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,867.5,50,,694,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,332.95,1431.38,
ER VISIT; LEVEL I W/ANCILLARY,11012601,CDM,450,RC,99282,HCPCS,Outpatient,,,215,215,,,,,,Other,Not Separately Reimbursable,177.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,177.38,82.5,,141.904,percent of total billed charges,Pays at 82.5% of total Billed charges,156.95,73,,125.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,150.5,70,,120.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.26,19.19,,33.008,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.5,50,,86,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.26,177.38,
ER VISIT; LEVEL II W/ANCILLARY,11012602,CDM,450,RC,99283,HCPCS,Outpatient,,,405,405,,,,,,Other,Not Separately Reimbursable,334.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,334.13,82.5,,267.304,percent of total billed charges,Pays at 82.5% of total Billed charges,295.65,73,,236.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,283.5,70,,226.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.72,19.19,,62.176,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,202.5,50,,162,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.72,334.13,
ER VISIT; LEVEL III W/ANCILLARY,11012603,CDM,450,RC,99284,HCPCS,Outpatient,,,541,541,,,,,,Other,Not Separately Reimbursable,446.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,446.33,82.5,,357.064,percent of total billed charges,Pays at 82.5% of total Billed charges,394.93,73,,315.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,378.7,70,,302.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.82,19.19,,83.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,270.5,50,,216.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.82,446.33,
ER VISIT; LEVEL IV W/ANCILLARY,11012604,CDM,450,RC,99285,HCPCS,Outpatient,,,876,876,,,,,,Other,Not Separately Reimbursable,722.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,722.7,82.5,,578.16,percent of total billed charges,Pays at 82.5% of total Billed charges,639.48,73,,511.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,613.2,70,,490.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,168.1,19.19,,134.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,438,50,,350.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,168.1,722.7,
ER VISIT; LEVEL V W/ANCILLARY,11012605,CDM,450,RC,99291,HCPCS,Outpatient,,,1262,1262,,,,,,Other,Not Separately Reimbursable,1041.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1041.15,82.5,,832.92,percent of total billed charges,Pays at 82.5% of total Billed charges,921.26,73,,737.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,883.4,70,,706.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,242.18,19.19,,193.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,631,50,,504.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,242.18,1041.15,
"ER VISIT; CRITICAL, < 74 MIN",11012607,CDM,450,RC,99292,HCPCS,Outpatient,,,1735,1735,,,,,,Other,Not Separately Reimbursable,1431.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1431.38,82.5,,1145.104,percent of total billed charges,Pays at 82.5% of total Billed charges,1266.55,73,,1013.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1214.5,70,,971.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,332.95,19.19,,266.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,867.5,50,,694,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,332.95,1431.38,
ER VISIT; CRITICAL ADD 30 MIN W/ANCILLAR,11012608,CDM,450,RC,92960,HCPCS,Outpatient,,,534,534,,,,,,Other,Not Separately Reimbursable,440.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,440.55,82.5,,352.44,percent of total billed charges,Pays at 82.5% of total Billed charges,389.82,73,,311.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,373.8,70,,299.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.47,19.19,,81.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,267,50,,213.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.47,440.55,
CARDIOVERSION,11012610,CDM,480,RC,92977,HCPCS,Outpatient,,,976,976,,,,,,Other,Not Separately Reimbursable,805.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,805.2,82.5,,644.16,percent of total billed charges,Pays at 82.5% of total Billed charges,712.48,73,,569.984,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,683.2,70,,546.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,187.29,19.19,,149.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,488,50,,390.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,187.29,805.2,
THROMBOLYTIC IV INFUSION,11012611,CDM,450,RC,36680,HCPCS,Outpatient,,,357,357,,,,,,Other,Not Separately Reimbursable,294.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,294.53,82.5,,235.624,percent of total billed charges,Pays at 82.5% of total Billed charges,260.61,73,,208.488,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,249.9,70,,199.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.51,19.19,,54.808,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,178.5,50,,142.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.51,294.53,
INTRA-OSSEOUS INFUSION,11012612,CDM,450,RC,92950,HCPCS,Outpatient,,,428,428,,,,,,Other,Not Separately Reimbursable,353.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,353.1,82.5,,282.48,percent of total billed charges,Pays at 82.5% of total Billed charges,312.44,73,,249.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,299.6,70,,239.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.13,19.19,,65.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214,50,,171.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.13,353.1,
CPR,11012613,CDM,450,RC,62270,HCPCS,Outpatient,,,852,852,,,,,,Other,Not Separately Reimbursable,702.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,702.9,82.5,,562.32,percent of total billed charges,Pays at 82.5% of total Billed charges,621.96,73,,497.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.4,70,,477.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.5,19.19,,130.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,426,50,,340.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.5,702.9,
DIAG SPINAL/LUMBAR PUNCT,11012614,CDM,450,RC,43762,HCPCS,Outpatient,,,998,998,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,728.54,73,,582.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,698.6,70,,558.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191.52,19.19,,153.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,499,50,,399.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191.52,982.8,
CHANGE GASTROSTOMY TUBE,11012616,CDM,450,RC,43753,HCPCS,Outpatient,,,496,496,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,362.08,73,,289.664,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,347.2,70,,277.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.18,19.19,,76.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,248,50,,198.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.18,982.8,
GASTRIC INTUBATION TREATMENT,11012617,CDM,750,RC,90471,HCPCS,Outpatient,,,183,183,,,,,,Other,Not Separately Reimbursable,150.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,150.98,82.5,,120.784,percent of total billed charges,Pays at 82.5% of total Billed charges,133.59,73,,106.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.1,70,,102.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.12,19.19,,28.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.5,50,,73.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.12,150.98,
Immunization administration by a medical assistant or nurse,11012620,CDM,450,RC,12001,HCPCS,Outpatient,,,105,105,,,,,,Other,Not Separately Reimbursable,86.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,86.63,82.5,,69.304,percent of total billed charges,Pays at 82.5% of total Billed charges,76.65,73,,61.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.5,70,,58.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,19.19,,16.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,50,,42,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,86.63,
"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",11012621,CDM,450,RC,12002,HCPCS,Outpatient,,,470,470,,,,,,Other,Not Separately Reimbursable,387.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,387.75,82.5,,310.2,percent of total billed charges,Pays at 82.5% of total Billed charges,343.1,73,,274.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329,70,,263.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,19.19,,72.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,235,50,,188,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,387.75,
SURG PROC SNT 2.6 CM TO 7.5 CM,11012622,CDM,450,RC,12004,HCPCS,Outpatient,,,470,470,,,,,,Other,Not Separately Reimbursable,387.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,387.75,82.5,,310.2,percent of total billed charges,Pays at 82.5% of total Billed charges,343.1,73,,274.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329,70,,263.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,19.19,,72.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,235,50,,188,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,387.75,
SURG PROC SNT 7.6 CM TO 12.5 CM,11012623,CDM,450,RC,12011,HCPCS,Outpatient,,,364,364,,,,,,Other,Not Separately Reimbursable,300.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,300.3,82.5,,240.24,percent of total billed charges,Pays at 82.5% of total Billed charges,265.72,73,,212.576,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,254.8,70,,203.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.85,19.19,,55.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182,50,,145.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.85,300.3,
"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes",11012625,CDM,450,RC,12013,HCPCS,Outpatient,,,471,471,,,,,,Other,Not Separately Reimbursable,388.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,388.58,82.5,,310.864,percent of total billed charges,Pays at 82.5% of total Billed charges,343.83,73,,275.064,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329.7,70,,263.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.38,19.19,,72.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,235.5,50,,188.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.38,388.58,
SURG PROC FEE 2.6 CM TO 5.0 CM,11012626,CDM,450,RC,12014,HCPCS,Outpatient,,,452,452,,,,,,Other,Not Separately Reimbursable,372.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,372.9,82.5,,298.32,percent of total billed charges,Pays at 82.5% of total Billed charges,329.96,73,,263.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,316.4,70,,253.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.74,19.19,,69.392,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,226,50,,180.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.74,372.9,
SURG PROC FEE 5.1 CM TO 7.5 CM,11012627,CDM,450,RC,12031,HCPCS,Outpatient,,,364,364,,,,,,Other,Not Separately Reimbursable,300.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,300.3,82.5,,240.24,percent of total billed charges,Pays at 82.5% of total Billed charges,265.72,73,,212.576,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,254.8,70,,203.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.85,19.19,,55.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182,50,,145.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.85,300.3,
INTER WOUNDS STE UP TO 2.5 CM,11012628,CDM,450,RC,12032,HCPCS,Outpatient,,,364,364,,,,,,Other,Not Separately Reimbursable,300.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,300.3,82.5,,240.24,percent of total billed charges,Pays at 82.5% of total Billed charges,265.72,73,,212.576,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,254.8,70,,203.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.85,19.19,,55.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182,50,,145.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.85,300.3,
INTER WOUNDS STE 2.6 TO 7.5 CM,11012629,CDM,450,RC,12034,HCPCS,Outpatient,,,413,413,,,,,,Other,Not Separately Reimbursable,340.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,340.73,82.5,,272.584,percent of total billed charges,Pays at 82.5% of total Billed charges,301.49,73,,241.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,289.1,70,,231.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.25,19.19,,63.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,206.5,50,,165.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.25,340.73,
INTER WOUNDS STE 7.6 TO 12.5 CM,11012630,CDM,450,RC,12041,HCPCS,Outpatient,,,382,382,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,278.86,73,,223.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,267.4,70,,213.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.31,19.19,,58.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191,50,,152.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.31,1319.85,
INTER WOUNDS NHF UP TO 2.5 CM,11012631,CDM,450,RC,12042,HCPCS,Outpatient,,,251,251,,,,,,Other,Not Separately Reimbursable,207.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,207.08,82.5,,165.664,percent of total billed charges,Pays at 82.5% of total Billed charges,183.23,73,,146.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175.7,70,,140.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.17,19.19,,38.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125.5,50,,100.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.17,207.08,
INTER WOUNDS NHF 2.6 TO 7.5 CM,11012632,CDM,450,RC,12044,HCPCS,Outpatient,,,264,264,,,,,,Other,Not Separately Reimbursable,217.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,217.8,82.5,,174.24,percent of total billed charges,Pays at 82.5% of total Billed charges,192.72,73,,154.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,184.8,70,,147.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.66,19.19,,40.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132,50,,105.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.66,217.8,
INTER WOUNDS NHF 7.6 TO 12.5 CM,11012633,CDM,450,RC,12051,HCPCS,Outpatient,,,1191,1191,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,869.43,73,,695.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,833.7,70,,666.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,228.55,19.19,,182.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595.5,50,,476.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,228.55,1319.85,
INTER WOUNDS FEEN UP TO 2.5 CM,11012634,CDM,450,RC,12052,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,170.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,170.78,82.5,,136.624,percent of total billed charges,Pays at 82.5% of total Billed charges,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,170.78,
INTER WOUNDS FEEN 2.6 CM TO 5.0 CM,11012635,CDM,450,RC,13100,HCPCS,Outpatient,,,279,279,,,,,,Other,Not Separately Reimbursable,230.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,230.18,82.5,,184.144,percent of total billed charges,Pays at 82.5% of total Billed charges,203.67,73,,162.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,195.3,70,,156.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.54,19.19,,42.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.5,50,,111.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.54,230.18,
COMPLEX WOUND REPAIR 1.1 CM TO 2.5 CM,11012637,CDM,450,RC,13120,HCPCS,Outpatient,,,908,908,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,662.84,73,,530.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,635.6,70,,508.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.25,19.19,,139.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,454,50,,363.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.25,1319.85,
COMP WOUND REPAIR SAL 1.1 TO 2.5 CM,11012638,CDM,450,RC,13131,HCPCS,Outpatient,,,256,256,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,186.88,73,,149.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.2,70,,143.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.13,19.19,,39.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128,50,,102.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.13,1319.85,
COMP WOUND REP FHF 1.1 CM TO 2.5 CM,11012639,CDM,450,RC,16000,HCPCS,Outpatient,,,373,373,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,272.29,73,,217.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,261.1,70,,208.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.58,19.19,,57.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.5,50,,149.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.58,1319.85,
INITIAL FIRST DEGREE BURN,11012640,CDM,450,RC,16020,HCPCS,Outpatient,,,248,248,,,,,,Other,Not Separately Reimbursable,204.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,204.6,82.5,,163.68,percent of total billed charges,Pays at 82.5% of total Billed charges,181.04,73,,144.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,173.6,70,,138.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.59,19.19,,38.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124,50,,99.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.59,204.6,
DRESS DEBRIDE SMALL WITH,11012641,CDM,450,RC,16020,HCPCS,Outpatient,,,242,242,,,,,,Other,Not Separately Reimbursable,199.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,199.65,82.5,,159.72,percent of total billed charges,Pays at 82.5% of total Billed charges,176.66,73,,141.328,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,169.4,70,,135.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.44,19.19,,37.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121,50,,96.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.44,199.65,
DRESS DEBRIDE SMALL W/O,11012642,CDM,450,RC,11730,HCPCS,Outpatient,,,242,242,,,,,,Other,Not Separately Reimbursable,199.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,199.65,82.5,,159.72,percent of total billed charges,Pays at 82.5% of total Billed charges,176.66,73,,141.328,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,169.4,70,,135.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.44,19.19,,37.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121,50,,96.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.44,199.65,
Separation and removal of the entire nail plate or a portion of nail plate,11012645,CDM,450,RC,11740,HCPCS,Outpatient,,,248,248,,,,,,Other,Not Separately Reimbursable,204.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,204.6,82.5,,163.68,percent of total billed charges,Pays at 82.5% of total Billed charges,181.04,73,,144.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,173.6,70,,138.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.59,19.19,,38.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124,50,,99.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.59,204.6,
DRAIN SUBUNGAL HEMATO,11012646,CDM,450,RC,11750,HCPCS,Outpatient,,,128,128,,,,,,Other,Not Separately Reimbursable,105.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,105.6,82.5,,84.48,percent of total billed charges,Pays at 82.5% of total Billed charges,93.44,73,,74.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.6,70,,71.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,19.19,,19.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64,50,,51.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,105.6,
EXCISION INGROWN NAIL(S),11012647,CDM,450,RC,10060,HCPCS,Outpatient,,,658,658,,,,,,Other,Not Separately Reimbursable,542.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,542.85,82.5,,434.28,percent of total billed charges,Pays at 82.5% of total Billed charges,480.34,73,,384.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,460.6,70,,368.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126.27,19.19,,101.016,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329,50,,263.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126.27,542.85,
Incision and drainage of abscess; simple or single and complex or multiple,11012648,CDM,450,RC,10120,HCPCS,Outpatient,,,480,480,,,,,,Other,Not Separately Reimbursable,396,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,396,82.5,,316.8,percent of total billed charges,Pays at 82.5% of total Billed charges,350.4,73,,280.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,336,70,,268.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.11,19.19,,73.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,240,50,,192,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.11,396,
I&D REMOVAL FB SIMPLE,11012650,CDM,450,RC,10140,HCPCS,Outpatient,,,746,746,,,,,,Other,Not Separately Reimbursable,615.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,615.45,82.5,,492.36,percent of total billed charges,Pays at 82.5% of total Billed charges,544.58,73,,435.664,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,522.2,70,,417.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.16,19.19,,114.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,373,50,,298.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.16,615.45,
"Incision and drainage of hematoma, seroma or fluid collection",11012651,CDM,450,RC,11042,HCPCS,Outpatient,,,1555,1555,,,,,,Other,Not Separately Reimbursable,1282.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1282.88,82.5,,1026.304,percent of total billed charges,Pays at 82.5% of total Billed charges,1135.15,73,,908.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1088.5,70,,870.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,298.4,19.19,,238.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,777.5,50,,622,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,298.4,1282.88,
DEBRIDE SKIN PARTIAL THICK,11012652,CDM,450,RC,10160,HCPCS,Outpatient,,,510,510,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,372.3,73,,297.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,357,70,,285.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,19.19,,78.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255,50,,204,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,1319.85,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",11012653,CDM,450,RC,69200,HCPCS,Outpatient,,,737,737,,,,,,Other,Not Separately Reimbursable,608.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,608.03,82.5,,486.424,percent of total billed charges,Pays at 82.5% of total Billed charges,538.01,73,,430.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,515.9,70,,412.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,141.43,19.19,,113.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,368.5,50,,294.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,141.43,608.03,
CLEAR OUTER EAR CANAL,11012654,CDM,450,RC,69210,HCPCS,Outpatient,,,183,183,,,,,,Other,Not Separately Reimbursable,150.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,150.98,82.5,,120.784,percent of total billed charges,Pays at 82.5% of total Billed charges,133.59,73,,106.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.1,70,,102.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.12,19.19,,28.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.5,50,,73.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.12,150.98,
Removal of ear wax from one or both ears,11012655,CDM,450,RC,30300,HCPCS,Outpatient,,,365,365,,,,,,Other,Not Separately Reimbursable,301.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,301.13,82.5,,240.904,percent of total billed charges,Pays at 82.5% of total Billed charges,266.45,73,,213.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255.5,70,,204.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.04,19.19,,56.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182.5,50,,146,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.04,301.13,
REMOVAL FB INTRA-NASAL,11012656,CDM,450,RC,30901,HCPCS,Outpatient,,,183,183,,,,,,Other,Not Separately Reimbursable,150.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,150.98,82.5,,120.784,percent of total billed charges,Pays at 82.5% of total Billed charges,133.59,73,,106.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.1,70,,102.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.12,19.19,,28.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.5,50,,73.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.12,150.98,
EPISTAX ANT UNI/BIL SIMPLE,11012657,CDM,450,RC,30903,HCPCS,Outpatient,,,309,309,,,,,,Other,Not Separately Reimbursable,254.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,254.93,82.5,,203.944,percent of total billed charges,Pays at 82.5% of total Billed charges,225.57,73,,180.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216.3,70,,173.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.3,19.19,,47.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154.5,50,,123.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.3,254.93,
EPISTAX ANT UNI/BL COMPLEX,11012658,CDM,450,RC,30905,HCPCS,Outpatient,,,241,241,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,175.93,73,,140.744,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,168.7,70,,134.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.25,19.19,,37,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,120.5,50,,96.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.25,982.8,
EPISTAXIS WITH POST PACK,11012659,CDM,450,RC,31500,HCPCS,Outpatient,,,365,365,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,266.45,73,,213.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255.5,70,,204.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.04,19.19,,56.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182.5,50,,146,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.04,982.8,
ENDOTRACHEAL INTUBATION,11012660,CDM,450,RC,42809,HCPCS,Outpatient,,,539,539,,,,,,Other,Not Separately Reimbursable,444.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,444.68,82.5,,355.744,percent of total billed charges,Pays at 82.5% of total Billed charges,393.47,73,,314.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,377.3,70,,301.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.43,19.19,,82.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,269.5,50,,215.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.43,444.68,
REMOVE FB LARYNGOSCOPY,11012661,CDM,450,RC,36430,HCPCS,Outpatient,,,183,183,,,,,,Other,Not Separately Reimbursable,150.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,150.98,82.5,,120.784,percent of total billed charges,Pays at 82.5% of total Billed charges,133.59,73,,106.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.1,70,,102.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.12,19.19,,28.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.5,50,,73.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.12,150.98,
BLOOD TRANSFUSION,11012662,CDM,391,RC,G0168,HCPCS,Outpatient,,,643,643,,,,,,Other,Not Separately Reimbursable,530.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,530.48,82.5,,424.384,percent of total billed charges,Pays at 82.5% of total Billed charges,469.39,73,,375.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,450.1,70,,360.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,123.39,19.19,,98.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,321.5,50,,257.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,123.39,530.48,
WOUND CLOSURE BY DERMABOND,11012663,CDM,450,RC,96375,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"INJECTION, IV ADD-ON",11012668,CDM,450,RC,96374,HCPCS,Outpatient,,,158,158,,,,,,Other,Not Separately Reimbursable,130.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,130.35,82.5,,104.28,percent of total billed charges,Pays at 82.5% of total Billed charges,115.34,73,,92.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110.6,70,,88.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.32,19.19,,24.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79,50,,63.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.32,130.35,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",11012669,CDM,450,RC,96372,HCPCS,Outpatient,,,365,365,,,,,,Other,Not Separately Reimbursable,301.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,301.13,82.5,,240.904,percent of total billed charges,Pays at 82.5% of total Billed charges,266.45,73,,213.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255.5,70,,204.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.04,19.19,,56.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182.5,50,,146,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.04,301.13,
INJECTION OF ANTIBIOTIC,11012670,CDM,450,RC,96372,HCPCS,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
"INJECTION, SC/IM",11012671,CDM,450,RC,67938,HCPCS,Outpatient,,,143,143,,,,,,Other,Not Separately Reimbursable,117.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,117.98,82.5,,94.384,percent of total billed charges,Pays at 82.5% of total Billed charges,104.39,73,,83.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.1,70,,80.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.44,19.19,,21.952,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.5,50,,57.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.44,117.98,
REMOVE FB CONJUNCTIVA,11012672,CDM,450,RC,23650,HCPCS,Outpatient,,,630,630,,,,,,Other,Not Separately Reimbursable,519.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,519.75,82.5,,415.8,percent of total billed charges,Pays at 82.5% of total Billed charges,459.9,73,,367.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,441,70,,352.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,120.9,19.19,,96.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,315,50,,252,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,120.9,519.75,
SHOULDER REDUCE W/O ANES,11012674,CDM,450,RC,23655,HCPCS,Outpatient,,,432,432,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,315.36,73,,252.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,302.4,70,,241.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.9,19.19,,66.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216,50,,172.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.9,982.8,
SHOULDER REDUCE W/ ANES,11012675,CDM,450,RC,24600,HCPCS,Outpatient,,,3747,3747,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,2735.31,73,,2188.248,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2622.9,70,,2098.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,719.05,19.19,,575.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1873.5,50,,1498.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,719.05,2735.31,
ELBOW DISCLOCATE W/O ANES,11012676,CDM,450,RC,27550,HCPCS,Outpatient,,,811,811,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,592.03,73,,473.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,567.7,70,,454.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.63,19.19,,124.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,405.5,50,,324.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.63,982.8,
KNEE DISCOLATION-W/O ANES,11012678,CDM,450,RC,26770,HCPCS,Outpatient,,,432,432,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,315.36,73,,252.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,302.4,70,,241.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.9,19.19,,66.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216,50,,172.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.9,982.8,
REDUCE IP JOINT W/O ANES,11012681,CDM,450,RC,26755,HCPCS,Outpatient,,,330,330,,,,,,Other,Not Separately Reimbursable,272.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,272.25,82.5,,217.8,percent of total billed charges,Pays at 82.5% of total Billed charges,240.9,73,,192.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,231,70,,184.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.33,19.19,,50.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165,50,,132,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.33,272.25,
CLOSED FINGER W/MANIPU,11012682,CDM,450,RC,26750,HCPCS,Outpatient,,,432,432,,,,,,Other,Not Separately Reimbursable,356.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,356.4,82.5,,285.12,percent of total billed charges,Pays at 82.5% of total Billed charges,315.36,73,,252.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,302.4,70,,241.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.9,19.19,,66.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216,50,,172.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.9,356.4,
CLOSED FINGER W/O MANIPU,11012683,CDM,450,RC,26700,HCPCS,Outpatient,,,432,432,,,,,,Other,Not Separately Reimbursable,356.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,356.4,82.5,,285.12,percent of total billed charges,Pays at 82.5% of total Billed charges,315.36,73,,252.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,302.4,70,,241.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.9,19.19,,66.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216,50,,172.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.9,356.4,
REDUCE PHALANX W/O ANES,11012684,CDM,450,RC,23500,HCPCS,Outpatient,,,432,432,,,,,,Other,Not Separately Reimbursable,356.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,356.4,82.5,,285.12,percent of total billed charges,Pays at 82.5% of total Billed charges,315.36,73,,252.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,302.4,70,,241.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.9,19.19,,66.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216,50,,172.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.9,356.4,
CLAVICLE FX W/O MANIPUL,11012685,CDM,450,RC,29550,HCPCS,Outpatient,,,432,432,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,315.36,73,,252.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,302.4,70,,241.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.9,19.19,,66.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216,50,,172.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.9,982.8,
TOE STRAPPING W/TAPE,11012686,CDM,450,RC,20605,HCPCS,Outpatient,,,404,404,,,,,,Other,Not Separately Reimbursable,333.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,333.3,82.5,,266.64,percent of total billed charges,Pays at 82.5% of total Billed charges,294.92,73,,235.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,282.8,70,,226.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.53,19.19,,62.024,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,202,50,,161.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.53,333.3,
Draining or injecting medication into a large joint/bursa without ultrasound,11012688,CDM,450,RC,20610,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately Reimbursable,207.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,207.9,82.5,,166.32,percent of total billed charges,Pays at 82.5% of total Billed charges,183.96,73,,147.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.4,70,,141.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.36,19.19,,38.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126,50,,100.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.36,207.9,
Draining or injecting medication into a major joint/bursa without ultrasound,11012689,CDM,450,RC,56420,HCPCS,Outpatient,,,1267,1267,,,,,,Other,Not Separately Reimbursable,1045.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1045.28,82.5,,836.224,percent of total billed charges,Pays at 82.5% of total Billed charges,924.91,73,,739.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,886.9,70,,709.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,243.14,19.19,,194.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,633.5,50,,506.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,243.14,1045.28,
I&D BARTHOLIN ABSCESS,11012691,CDM,450,RC,51701,HCPCS,Outpatient,,,447,447,,,,,,Other,Not Separately Reimbursable,368.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,368.78,82.5,,295.024,percent of total billed charges,Pays at 82.5% of total Billed charges,326.31,73,,261.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,312.9,70,,250.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85.78,19.19,,68.624,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,223.5,50,,178.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85.78,368.78,
BLADDER CATH SIMPLE,11012692,CDM,450,RC,54450,HCPCS,Outpatient,,,276,276,,,,,,Other,Not Separately Reimbursable,227.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,227.7,82.5,,182.16,percent of total billed charges,Pays at 82.5% of total Billed charges,201.48,73,,161.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,193.2,70,,154.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.96,19.19,,42.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,138,50,,110.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.96,227.7,
FORESKIN MANIPULATION,11012693,CDM,450,RC,51702,HCPCS,Outpatient,,,545,545,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,397.85,73,,318.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,381.5,70,,305.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.59,19.19,,83.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,272.5,50,,218,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.59,982.8,
INS OF FOLEY CATHETER,11012695,CDM,450,RC,29065,HCPCS,Outpatient,,,183,183,,,,,,Other,Not Separately Reimbursable,150.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,150.98,82.5,,120.784,percent of total billed charges,Pays at 82.5% of total Billed charges,133.59,73,,106.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.1,70,,102.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.12,19.19,,28.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.5,50,,73.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.12,150.98,
CASTING OF LONG ARM,11012699,CDM,450,RC,29075,HCPCS,Outpatient,,,695,695,,,,,,Other,Not Separately Reimbursable,573.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,573.38,82.5,,458.704,percent of total billed charges,Pays at 82.5% of total Billed charges,507.35,73,,405.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,486.5,70,,389.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133.37,19.19,,106.696,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,347.5,50,,278,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133.37,573.38,
CASTING OF SHORT ARM,11012700,CDM,450,RC,29405,HCPCS,Outpatient,,,406,406,,,,,,Other,Not Separately Reimbursable,334.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,334.95,82.5,,267.96,percent of total billed charges,Pays at 82.5% of total Billed charges,296.38,73,,237.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,284.2,70,,227.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.91,19.19,,62.328,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203,50,,162.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.91,334.95,
CASTING OF SHORT LEG,11012703,CDM,450,RC,29105,HCPCS,Outpatient,,,406,406,,,,,,Other,Not Separately Reimbursable,334.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,334.95,82.5,,267.96,percent of total billed charges,Pays at 82.5% of total Billed charges,296.38,73,,237.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,284.2,70,,227.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.91,19.19,,62.328,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203,50,,162.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.91,334.95,
APPLICATION OF SPLINT LONG ARM,11012704,CDM,450,RC,29125,HCPCS,Outpatient,,,374,374,,,,,,Other,Not Separately Reimbursable,308.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,308.55,82.5,,246.84,percent of total billed charges,Pays at 82.5% of total Billed charges,273.02,73,,218.416,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,261.8,70,,209.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.77,19.19,,57.416,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,187,50,,149.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.77,308.55,
APPLICATION OF SPLINT SHORT ARM,11012705,CDM,450,RC,29130,HCPCS,Outpatient,,,376,376,,,,,,Other,Not Separately Reimbursable,310.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,310.2,82.5,,248.16,percent of total billed charges,Pays at 82.5% of total Billed charges,274.48,73,,219.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,263.2,70,,210.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.15,19.19,,57.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,188,50,,150.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.15,310.2,
APPLICATION OF SPLINT FINGER,11012706,CDM,450,RC,29505,HCPCS,Outpatient,,,306,306,,,,,,Other,Not Separately Reimbursable,252.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,252.45,82.5,,201.96,percent of total billed charges,Pays at 82.5% of total Billed charges,223.38,73,,178.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.2,70,,171.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,19.19,,46.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153,50,,122.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,252.45,
APPLICATION OF SPLINT LONG LEG,11012707,CDM,450,RC,29515,HCPCS,Outpatient,,,369,369,,,,,,Other,Not Separately Reimbursable,304.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,304.43,82.5,,243.544,percent of total billed charges,Pays at 82.5% of total Billed charges,269.37,73,,215.496,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,258.3,70,,206.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.81,19.19,,56.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,184.5,50,,147.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.81,304.43,
APPLICATION OF SPLINT SHORT LEG,11012708,CDM,450,RC,29540,HCPCS,Outpatient,,,407,407,,,,,,Other,Not Separately Reimbursable,335.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,335.78,82.5,,268.624,percent of total billed charges,Pays at 82.5% of total Billed charges,297.11,73,,237.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,284.9,70,,227.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.1,19.19,,62.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.5,50,,162.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.1,335.78,
STRAPPING OF ANKLE,11012709,CDM,450,RC,29260,HCPCS,Outpatient,,,400,400,,,,,,Other,Not Separately Reimbursable,330,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,330,82.5,,264,percent of total billed charges,Pays at 82.5% of total Billed charges,292,73,,233.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280,70,,224,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.76,19.19,,61.408,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,200,50,,160,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.76,330,
STRAPPING OF ELBOW OR WRIST,11012710,CDM,450,RC,29280,HCPCS,Outpatient,,,306,306,,,,,,Other,Not Separately Reimbursable,252.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,252.45,82.5,,201.96,percent of total billed charges,Pays at 82.5% of total Billed charges,223.38,73,,178.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.2,70,,171.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,19.19,,46.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153,50,,122.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,252.45,
STRAPPING OF FINGER OR HAND,11012711,CDM,450,RC,29540,HCPCS,Outpatient,,,306,306,,,,,,Other,Not Separately Reimbursable,252.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,252.45,82.5,,201.96,percent of total billed charges,Pays at 82.5% of total Billed charges,223.38,73,,178.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.2,70,,171.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,19.19,,46.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153,50,,122.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,252.45,
STRAPPING OF FOOT,11012712,CDM,450,RC,29530,HCPCS,Outpatient,,,297,297,,,,,,Other,Not Separately Reimbursable,245.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,245.03,82.5,,196.024,percent of total billed charges,Pays at 82.5% of total Billed charges,216.81,73,,173.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,207.9,70,,166.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.99,19.19,,45.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.5,50,,118.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.99,245.03,
STRAPPING OF KNEE,11012713,CDM,450,RC,29240,HCPCS,Outpatient,,,306,306,,,,,,Other,Not Separately Reimbursable,252.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,252.45,82.5,,201.96,percent of total billed charges,Pays at 82.5% of total Billed charges,223.38,73,,178.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.2,70,,171.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,19.19,,46.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153,50,,122.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,252.45,
STRAPPING OF SHOULDER,11012714,CDM,761,RC,36555,HCPCS,Outpatient,,,306,306,,,,,,Other,Not Separately Reimbursable,252.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,252.45,82.5,,201.96,percent of total billed charges,Pays at 82.5% of total Billed charges,223.38,73,,178.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.2,70,,171.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,19.19,,46.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153,50,,122.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,252.45,
CENTRAL LINE INSERTION < 5 YRS,11012715,CDM,450,RC,59409,HCPCS,Outpatient,,,2740,2740,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,2000.2,73,,1600.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1918,70,,1534.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,525.81,19.19,,420.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1370,50,,1096,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,525.81,2000.2,
Vaginal delivery,11012716,CDM,450,RC,12015,HCPCS,Outpatient,,,4650,4650,,,,,,Other,Not Separately Reimbursable,3836.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3836.25,82.5,,3069,percent of total billed charges,Pays at 82.5% of total Billed charges,3394.5,73,,2715.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3255,70,,2604,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,892.34,19.19,,713.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2325,50,,1860,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,892.34,3836.25,
SURG PROC FEE 7.6CM TO 12.5CM,11012720,CDM,450,RC,12035,HCPCS,Outpatient,,,442,442,,,,,,Other,Not Separately Reimbursable,364.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,364.65,82.5,,291.72,percent of total billed charges,Pays at 82.5% of total Billed charges,322.66,73,,258.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,309.4,70,,247.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.82,19.19,,67.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,221,50,,176.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.82,364.65,
SCALP TRUNK EXTR 12.6 CM TO 20,11012726,CDM,450,RC,12045,HCPCS,Outpatient,,,424,424,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,309.52,73,,247.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,296.8,70,,237.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.37,19.19,,65.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,212,50,,169.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.37,1319.85,
NECK HANDS FEET 12.6 TO 20 CM,11012729,CDM,450,RC,23500,HCPCS,Outpatient,,,264,264,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,192.72,73,,154.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,184.8,70,,147.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.66,19.19,,40.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132,50,,105.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.66,1319.85,
STRAPPING OF CLAVICLE,11012730,CDM,450,RC,92953,HCPCS,Outpatient,,,292,292,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,213.16,73,,170.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,204.4,70,,163.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.03,19.19,,44.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,146,50,,116.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.03,982.8,
TRANSCUTANEOUS PACING,11012731,CDM,450,RC,13121,HCPCS,Outpatient,,,432,432,,,,,,Other,Not Separately Reimbursable,356.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,356.4,82.5,,285.12,percent of total billed charges,Pays at 82.5% of total Billed charges,315.36,73,,252.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,302.4,70,,241.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.9,19.19,,66.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216,50,,172.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.9,356.4,
COMP WD SCALP ARMS LEG 2.6-7.5CM,11012740,CDM,450,RC,13122,HCPCS,Outpatient,,,1090,1090,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,795.7,73,,636.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,763,70,,610.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,209.17,19.19,,167.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,545,50,,436,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,209.17,1508.85,
SCALP ARMS LEGS EA ADD 5 CM OR LESS,11012741,CDM,450,RC,13132,HCPCS,Outpatient,,,256,256,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,186.88,73,,149.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.2,70,,143.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.13,19.19,,39.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128,50,,102.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.13,982.8,
FOREHEAD HANDS FEET 2.6-7.5 CM,11012742,CDM,450,RC,13151,HCPCS,Outpatient,,,369,369,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,269.37,73,,215.496,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,258.3,70,,206.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.81,19.19,,56.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,184.5,50,,147.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.81,1508.85,
EYELIDS NOSE EARS LIPS 1.1CM-2.5CM,11012745,CDM,450,RC,13152,HCPCS,Outpatient,,,908,908,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,662.84,73,,530.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,635.6,70,,508.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.25,19.19,,139.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,454,50,,363.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.25,1508.85,
EYELIDS NOSE EARS LIPS 2.6CM-7.5CM,11012746,CDM,450,RC,10060,HCPCS,Outpatient,,,866,866,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,632.18,73,,505.744,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,606.2,70,,484.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.19,19.19,,132.952,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,433,50,,346.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.19,1508.85,
Incision and drainage of abscess; simple or single and complex or multiple,11012748,CDM,450,RC,65222,HCPCS,Outpatient,,,480,480,,,,,,Other,Not Separately Reimbursable,396,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,396,82.5,,316.8,percent of total billed charges,Pays at 82.5% of total Billed charges,350.4,73,,280.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,336,70,,268.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.11,19.19,,73.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,240,50,,192,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.11,396,
FB CORNEAL W/SLIT LAMP,11012749,CDM,450,RC,10121,HCPCS,Outpatient,,,265,265,,,,,,Other,Not Separately Reimbursable,218.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,218.63,82.5,,174.904,percent of total billed charges,Pays at 82.5% of total Billed charges,193.45,73,,154.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,185.5,70,,148.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.85,19.19,,40.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.5,50,,106,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.85,218.63,
I&D REMOVAL FB COMPLEX,11012750,CDM,450,RC,11444,HCPCS,Outpatient,,,2686,2686,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1960.78,73,,1568.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1880.2,70,,1504.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,515.44,19.19,,412.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1343,50,,1074.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,515.44,1960.78,
EXC BENIGN 3.1-4 CM,11012754,CDM,450,RC,27788,HCPCS,Outpatient,,,2183,2183,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1593.59,73,,1274.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1528.1,70,,1222.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,418.92,19.19,,335.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1091.5,50,,873.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,418.92,1593.59,
TX FX/DISLOCATION LOWER LEG/ANKLE,11012788,CDM,450,RC,99211,HCPCS,Outpatient,,,355,355,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,259.15,73,,207.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,248.5,70,,198.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.12,19.19,,54.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177.5,50,,142,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.12,982.8,
Outpatient visit of established patient not requiring a physician,11012900,CDM,510,RC,99212,HCPCS,Outpatient,,,128,128,,,,,,Other,Not Separately Reimbursable,105.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,105.6,82.5,,84.48,percent of total billed charges,Pays at 82.5% of total Billed charges,93.44,73,,74.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.6,70,,71.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,19.19,,19.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64,50,,51.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,105.6,
Outpatient visit of established patient requiring a physician,11012902,CDM,510,RC,99213,HCPCS,Outpatient,,,204,204,,,,,,Other,Not Separately Reimbursable,168.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,168.3,82.5,,134.64,percent of total billed charges,Pays at 82.5% of total Billed charges,148.92,73,,119.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,142.8,70,,114.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.15,19.19,,31.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102,50,,81.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.15,168.3,
"Established patient office or other outpatient visit, typically 15 minutes",11012904,CDM,510,RC,99214,HCPCS,Outpatient,,,213,213,,,,,,Other,Not Separately Reimbursable,175.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,175.73,82.5,,140.584,percent of total billed charges,Pays at 82.5% of total Billed charges,155.49,73,,124.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.1,70,,119.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.87,19.19,,32.696,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,106.5,50,,85.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.87,175.73,
"Established patient office or other outpatient visit, typically 25 minutes",11012906,CDM,510,RC,99215,HCPCS,Outpatient,,,243,243,,,,,,Other,Not Separately Reimbursable,200.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,200.48,82.5,,160.384,percent of total billed charges,Pays at 82.5% of total Billed charges,177.39,73,,141.912,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.1,70,,136.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.63,19.19,,37.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121.5,50,,97.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.63,200.48,
"Established patient office or other outpatient, visit typically 40 minutes",11012908,CDM,510,RC,13160,HCPCS,Outpatient,,,313,313,,,,,,Other,Not Separately Reimbursable,258.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,258.23,82.5,,206.584,percent of total billed charges,Pays at 82.5% of total Billed charges,228.49,73,,182.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,219.1,70,,175.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.06,19.19,,48.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,156.5,50,,125.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.06,258.23,
SEC CLSR SURG WND/DEHSN EXT/COMPLICATED,11013160,CDM,450,RC,20102,HCPCS,Outpatient,,,5011,5011,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,3658.03,73,,2926.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3507.7,70,,2806.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,961.61,19.19,,769.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2505.5,50,,2004.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,961.61,3658.03,
EXPLORATION PEN WND ABD/FLANK/BACK,11020102,CDM,450,RC,20520,HCPCS,Outpatient,,,5011,5011,,,,,,Other,Not Separately Reimbursable,4134.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4134.08,82.5,,3307.264,percent of total billed charges,Pays at 82.5% of total Billed charges,3658.03,73,,2926.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3507.7,70,,2806.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,961.61,19.19,,769.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2505.5,50,,2004.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,961.61,4134.08,
REMOVAL FOREIGN BODY MUSCLE/TENDON; SIMP,11020520,CDM,450,RC,21480,HCPCS,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,123.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,123.75,82.5,,99,percent of total billed charges,Pays at 82.5% of total Billed charges,109.5,73,,87.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,70,,84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,19.19,,23.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75,50,,60,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,123.75,
CLSD TRMT TEMPOROMANDIBLULAR DISLOCATION,11021480,CDM,450,RC,23625,HCPCS,Outpatient,,,500,500,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,365,73,,292,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,350,70,,280,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.95,19.19,,76.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,250,50,,200,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.95,982.8,
CLOSED TX GREATER HUMERAL TUBEROSITY FX,11023625,CDM,450,RC,23675,HCPCS,Outpatient,,,4685,4685,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,3420.05,73,,2736.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3279.5,70,,2623.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,899.05,19.19,,719.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2342.5,50,,1874,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,899.05,3420.05,
CLOSED TX SHOULDER DISLOCATION,11023675,CDM,450,RC,26011,HCPCS,Outpatient,,,2599,2599,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1897.27,73,,1517.816,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1819.3,70,,1455.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,498.75,19.19,,399,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1299.5,50,,1039.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,498.75,1897.27,
"DRAINAGE OF FINGER ABCESS, COMPLEX",11026011,CDM,450,RC,26670,HCPCS,Outpatient,,,2926,2926,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,2135.98,73,,1708.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2048.2,70,,1638.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,561.5,19.19,,449.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1463,50,,1170.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,561.5,2135.98,
CLSED TX DISLOCATION DIGIT W/O ANESTHESI,11026670,CDM,450,RC,27788,HCPCS,Outpatient,,,432,432,,,,,,Other,Not Separately Reimbursable,356.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,356.4,82.5,,285.12,percent of total billed charges,Pays at 82.5% of total Billed charges,315.36,73,,252.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,302.4,70,,241.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.9,19.19,,66.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216,50,,172.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.9,356.4,
TX OF FX/DISLOCATION-LOWER LEG/ANKLE,11027788,CDM,450,RC,28192,HCPCS,Outpatient,,,355,355,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,259.15,73,,207.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,248.5,70,,198.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.12,19.19,,54.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177.5,50,,142,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.12,982.8,
"REMOVAL OF FOREIGN BODY,FOOT;DEEP",11028192,CDM,450,RC,28660,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,584,73,,467.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,560,70,,448,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153.52,19.19,,122.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,400,50,,320,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153.52,1319.85,
CL TX INTERPHALANGEAL JNT DIS W/O ANES,11028660,CDM,450,RC,29085,HCPCS,Outpatient,,,355,355,,,,,,Other,Not Separately Reimbursable,292.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,292.88,82.5,,234.304,percent of total billed charges,Pays at 82.5% of total Billed charges,259.15,73,,207.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,248.5,70,,198.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.12,19.19,,54.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177.5,50,,142,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.12,292.88,
APPLICATION CAST HAND&LOWER F/ARM GAUNTL,11029085,CDM,450,RC,29086,HCPCS,Outpatient,,,306,306,,,,,,Other,Not Separately Reimbursable,252.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,252.45,82.5,,201.96,percent of total billed charges,Pays at 82.5% of total Billed charges,223.38,73,,178.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.2,70,,171.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,19.19,,46.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153,50,,122.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,252.45,
APPLICATION CAST FINGER,11029086,CDM,450,RC,29126,HCPCS,Outpatient,,,306,306,,,,,,Other,Not Separately Reimbursable,252.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,252.45,82.5,,201.96,percent of total billed charges,Pays at 82.5% of total Billed charges,223.38,73,,178.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.2,70,,171.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,19.19,,46.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153,50,,122.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,252.45,
APPLICATION SHORT ARM SPLINT DYNAMIC,11029126,CDM,450,RC,29131,HCPCS,Outpatient,,,201,201,,,,,,Other,Not Separately Reimbursable,165.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,165.83,82.5,,132.664,percent of total billed charges,Pays at 82.5% of total Billed charges,146.73,73,,117.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140.7,70,,112.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.57,19.19,,30.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.5,50,,80.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.57,165.83,
APPLICATION FINGER SPLINT DYNAMIC,11029131,CDM,450,RC,20600,HCPCS,Outpatient,,,306,306,,,,,,Other,Not Separately Reimbursable,252.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,252.45,82.5,,201.96,percent of total billed charges,Pays at 82.5% of total Billed charges,223.38,73,,178.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.2,70,,171.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,19.19,,46.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153,50,,122.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,252.45,
Draining or injecting medication into a small joint/bursa without ultrasound,11029799,CDM,450,RC,31238,HCPCS,Outpatient,,,448,448,,,,,,Other,Not Separately Reimbursable,369.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,369.6,82.5,,295.68,percent of total billed charges,Pays at 82.5% of total Billed charges,327.04,73,,261.632,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,313.6,70,,250.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85.97,19.19,,68.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,224,50,,179.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85.97,369.6,
"NASAL/SINUS ENDOSCOPY,SURGICAL;W/BIOPSY",11031238,CDM,450,RC,36556,HCPCS,Outpatient,,,4936,4936,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,3603.28,73,,2882.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3455.2,70,,2764.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,947.22,19.19,,757.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2468,50,,1974.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,947.22,3603.28,
CENTRAL LINE INSERTION > 5 YRS,11036556,CDM,450,RC,36591,HCPCS,Outpatient,,,1858,1858,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1356.34,73,,1085.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1300.6,70,,1040.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,356.55,19.19,,285.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,929,50,,743.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,356.55,1356.34,
BLOOD DRAW FROM IMPLANT VENOUS ACCESS,11036591,CDM,450,RC,36592,HCPCS,Outpatient,,,77,77,,,,,,Other,Not Separately Reimbursable,63.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,63.53,82.5,,50.824,percent of total billed charges,Pays at 82.5% of total Billed charges,56.21,73,,44.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.9,70,,43.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,19.19,,11.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,50,,30.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,63.53,
COLLECT BLOOD FROM CATHETER VENOUS NOS,11036592,CDM,450,RC,36680,HCPCS,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,93.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,93.23,82.5,,74.584,percent of total billed charges,Pays at 82.5% of total Billed charges,82.49,73,,65.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.1,70,,63.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,19.19,,17.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.5,50,,45.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,93.23,
PLMT NDL INTROSS NFS,11036680,CDM,450,RC,37609,HCPCS,Outpatient,,,428,428,,,,,,Other,Not Separately Reimbursable,353.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,353.1,82.5,,282.48,percent of total billed charges,Pays at 82.5% of total Billed charges,312.44,73,,249.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,299.6,70,,239.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.13,19.19,,65.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214,50,,171.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.13,353.1,
"LIGATION OR BIOPSY, TEMPORAL ARTERY",11037609,CDM,450,RC,40800,HCPCS,Outpatient,,,4044,4044,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,2952.12,73,,2361.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2830.8,70,,2264.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,776.04,19.19,,620.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2022,50,,1617.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,776.04,2952.12,
DRAINAGE OF ABSCESS IN MOUTH-SIMPLE,11040800,CDM,450,RC,40804,HCPCS,Outpatient,,,250,250,,,,,,Other,Not Separately Reimbursable,206.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,206.25,82.5,,165,percent of total billed charges,Pays at 82.5% of total Billed charges,182.5,73,,146,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,70,,140,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,19.19,,38.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125,50,,100,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,206.25,
REM OF EMBED FOREIGN BODY VESTIBUL MOUTH,11040804,CDM,450,RC,41017,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,165,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,165,82.5,,132,percent of total billed charges,Pays at 82.5% of total Billed charges,146,73,,116.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,70,,112,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,19.19,,30.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100,50,,80,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,165,
"EXTRAORAL I & D, SUBMANDIBULAR",11041017,CDM,450,RC,43762,HCPCS,Outpatient,,,2199,2199,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1605.27,73,,1284.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1539.3,70,,1231.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,421.99,19.19,,337.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1099.5,50,,879.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,421.99,1605.27,
REPLACE GASTR TUBE PERCUT W/O IMAG/REVIS,11043762,CDM,450,RC,43763,HCPCS,Outpatient,,,496,496,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,362.08,73,,289.664,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,347.2,70,,277.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.18,19.19,,76.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,248,50,,198.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.18,982.8,
REPLACE GASTR TUBE PERCUT W/O IMAG W/REV,11043763,CDM,450,RC,46083,HCPCS,Outpatient,,,550,550,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,401.5,73,,321.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,385,70,,308,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.55,19.19,,84.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,275,50,,220,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.55,982.8,
INCISION OF THROMBOSED HEMORRHOID EXTERN,11046083,CDM,450,RC,49082,HCPCS,Outpatient,,,500,500,,,,,,Other,Not Separately Reimbursable,412.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,412.5,82.5,,330,percent of total billed charges,Pays at 82.5% of total Billed charges,365,73,,292,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,350,70,,280,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.95,19.19,,76.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,250,50,,200,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.95,412.5,
ABDOMINAL PARACENTESIS W/OIMAGING GUID,11049082,CDM,450,RC,49083,HCPCS,Outpatient,,,2230,2230,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1627.9,73,,1302.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1561,70,,1248.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,427.94,19.19,,342.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1115,50,,892,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,427.94,1627.9,
ABDOMINAL PARACENTESIS W/IMAGING GUIDANC,11049083,CDM,450,RC,49440,HCPCS,Outpatient,,,2230,2230,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1627.9,73,,1302.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1561,70,,1248.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,427.94,19.19,,342.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1115,50,,892,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,427.94,1627.9,
"INSERTION OF GASTROSTOMY TUBE, PERCUTANE",11049440,CDM,450,RC,51700,HCPCS,Outpatient,,,1997,1997,,,,,,Other,Not Separately Reimbursable,1647.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1647.53,82.5,,1318.024,percent of total billed charges,Pays at 82.5% of total Billed charges,1457.81,73,,1166.248,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1397.9,70,,1118.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,383.22,19.19,,306.576,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,998.5,50,,798.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,383.22,1647.53,
BLADDER IRRIGATION/INSTALLATION,11051700,CDM,450,RC,51705,HCPCS,Outpatient,,,556,556,,,,,,Other,Not Separately Reimbursable,458.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,458.7,82.5,,366.96,percent of total billed charges,Pays at 82.5% of total Billed charges,405.88,73,,324.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,389.2,70,,311.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,106.7,19.19,,85.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,278,50,,222.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,106.7,458.7,
CHANGE CYSTOSTOMY TUBE: SINGLE,11051705,CDM,450,RC,56405,HCPCS,Outpatient,,,272,272,,,,,,Other,Not Separately Reimbursable,224.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,224.4,82.5,,179.52,percent of total billed charges,Pays at 82.5% of total Billed charges,198.56,73,,158.848,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,190.4,70,,152.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.2,19.19,,41.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,136,50,,108.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.2,224.4,
I&D OF PERINEAL ABSCESS-FEMALE ONLY,11056405,CDM,450,RC,64402,HCPCS,Outpatient,,,520,520,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,379.6,73,,303.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,364,70,,291.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.79,19.19,,79.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,260,50,,208,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.79,1319.85,
"N BLOCK INJ, FACIAL",11064402,CDM,450,RC,67700,HCPCS,Outpatient,,,561,561,,,,,,Other,Not Separately Reimbursable,462.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,462.83,82.5,,370.264,percent of total billed charges,Pays at 82.5% of total Billed charges,409.53,73,,327.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,392.7,70,,314.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.66,19.19,,86.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280.5,50,,224.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.66,462.83,
"BLEPHAROTOMY, ABSCESS DRAINAGE, EYELID",11067700,CDM,450,RC,69000,HCPCS,Outpatient,,,731,731,,,,,,Other,Not Separately Reimbursable,603.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,603.08,82.5,,482.464,percent of total billed charges,Pays at 82.5% of total Billed charges,533.63,73,,426.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,511.7,70,,409.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140.28,19.19,,112.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,365.5,50,,292.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140.28,603.08,
"DRAIN EXTERNAL EAR, ABSCESS OR HEMATOMA",11069000,CDM,450,RC,86580,HCPCS,Outpatient,,,335,335,,,,,,Other,Not Separately Reimbursable,276.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,276.38,82.5,,221.104,percent of total billed charges,Pays at 82.5% of total Billed charges,244.55,73,,195.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,234.5,70,,187.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.29,19.19,,51.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,167.5,50,,134,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.29,276.38,
"SKIN TEST, TB, INTRADERMAL",11086580,CDM,302,RC,96360,HCPCS,Outpatient,,,34,34,,,,,,Other,Not Separately Reimbursable,28.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.05,82.5,,22.44,percent of total billed charges,Pays at 82.5% of total Billed charges,24.82,73,,19.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,70,,19.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,19.19,,5.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17,50,,13.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,28.05,
HYDRATION IV INFUSION; INITIAL,11090760,CDM,450,RC,96361,HCPCS,Outpatient,,,363,363,,,,,,Other,Not Separately Reimbursable,299.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,299.48,82.5,,239.584,percent of total billed charges,Pays at 82.5% of total Billed charges,264.99,73,,211.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,254.1,70,,203.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.66,19.19,,55.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,181.5,50,,145.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.66,299.48,
HYDRATION IV INFUSION; ADD-ON,11090761,CDM,450,RC,96365,HCPCS,Outpatient,,,134,134,,,,,,Other,Not Separately Reimbursable,110.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,110.55,82.5,,88.44,percent of total billed charges,Pays at 82.5% of total Billed charges,97.82,73,,78.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.8,70,,75.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.71,19.19,,20.568,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67,50,,53.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.71,110.55,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",11090765,CDM,450,RC,96366,HCPCS,Outpatient,,,402,402,,,,,,Other,Not Separately Reimbursable,331.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,331.65,82.5,,265.32,percent of total billed charges,Pays at 82.5% of total Billed charges,293.46,73,,234.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,281.4,70,,225.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.14,19.19,,61.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,201,50,,160.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.14,331.65,
"INFUSION, IV ADD-ON",11090766,CDM,450,RC,96367,HCPCS,Outpatient,,,169,169,,,,,,Other,Not Separately Reimbursable,139.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,139.43,82.5,,111.544,percent of total billed charges,Pays at 82.5% of total Billed charges,123.37,73,,98.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,118.3,70,,94.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.43,19.19,,25.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.5,50,,67.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.43,139.43,
"INFUSION, IV SEQUENTIAL DRUG",11090767,CDM,450,RC,96368,HCPCS,Outpatient,,,279,279,,,,,,Other,Not Separately Reimbursable,230.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,230.18,82.5,,184.144,percent of total billed charges,Pays at 82.5% of total Billed charges,203.67,73,,162.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,195.3,70,,156.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.54,19.19,,42.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.5,50,,111.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.54,230.18,
"INFUSION, IV CONCURRENT DRUG",11090768,CDM,450,RC,96523,HCPCS,Outpatient,,,198,198,,,,,,Other,Not Separately Reimbursable,163.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,163.35,82.5,,130.68,percent of total billed charges,Pays at 82.5% of total Billed charges,144.54,73,,115.632,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,138.6,70,,110.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,19.19,,30.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99,50,,79.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,163.35,
IRRG IMPLAN VEN ACC DEV FOR DRUG DELIVER,11096523,CDM,450,RC,99148,HCPCS,Outpatient,,,67,67,,,,,,Other,Not Separately Reimbursable,55.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,55.28,82.5,,44.224,percent of total billed charges,Pays at 82.5% of total Billed charges,48.91,73,,39.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,70,,37.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,19.19,,10.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.5,50,,26.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,55.28,
M-SEDATION PHY/OTH THN PRFMG < 5 YRS,11099148,CDM,370,RC,99150,HCPCS,Outpatient,,,321,321,,,,,,Other,Not Separately Reimbursable,264.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,264.83,82.5,,211.864,percent of total billed charges,Pays at 82.5% of total Billed charges,234.33,73,,187.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,224.7,70,,179.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,19.19,,49.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,160.5,50,,128.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,264.83,
M-SEDAJ PHY/OTH THN PRFMG EA 15 MIN,11099150,CDM,370,RC,99155,HCPCS,Outpatient,,,134,134,,,,,,Other,Not Separately Reimbursable,110.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,110.55,82.5,,88.44,percent of total billed charges,Pays at 82.5% of total Billed charges,97.82,73,,78.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.8,70,,75.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.71,19.19,,20.568,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67,50,,53.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.71,110.55,
M-SEDATION PHY/OTH THN PRFMG < 5 YRS,11099155,CDM,370,RC,99195,HCPCS,Outpatient,,,321,321,,,,,,Other,Not Separately Reimbursable,264.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,264.83,82.5,,211.864,percent of total billed charges,Pays at 82.5% of total Billed charges,234.33,73,,187.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,224.7,70,,179.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,19.19,,49.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,160.5,50,,128.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,264.83,
PHLEBOTOMY THER SPX,11099195,CDM,450,RC,11200,HCPCS,Outpatient,,,127,127,,,,,,Other,Not Separately Reimbursable,104.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,104.78,82.5,,83.824,percent of total billed charges,Pays at 82.5% of total Billed charges,92.71,73,,74.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.9,70,,71.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.37,19.19,,19.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.5,50,,50.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.37,104.78,
"Removal of skin tags, multiple fibrocutaneous tags, any area",12011200,CDM,510,RC,12006,HCPCS,Outpatient,,,170,170,,,,,,Other,Not Separately Reimbursable,140.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,140.25,82.5,,112.2,percent of total billed charges,Pays at 82.5% of total Billed charges,124.1,73,,99.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,119,70,,95.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.62,19.19,,26.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85,50,,68,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.62,140.25,
ERP REPA SUPERFICIAL WND BODY20.1-30.0CM,12012006,CDM,510,RC,65222,HCPCS,Outpatient,,,278,278,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,202.94,73,,162.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,194.6,70,,155.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.35,19.19,,42.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139,50,,111.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.35,1319.85,
FB CORNEAL W/SLIT LAMP,12065222,CDM,450,RC,96372,HCPCS,Outpatient,,,265,265,,,,,,Other,Not Separately Reimbursable,218.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,218.63,82.5,,174.904,percent of total billed charges,Pays at 82.5% of total Billed charges,193.45,73,,154.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,185.5,70,,148.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.85,19.19,,40.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.5,50,,106,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.85,218.63,
"INJECTION, SC/IM",12090772,CDM,510,RC,G0277,HCPCS,Outpatient,,,7,7,,,,,,Other,Not Separately Reimbursable,5.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5.78,82.5,,4.624,percent of total billed charges,Pays at 82.5% of total Billed charges,5.11,73,,4.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.9,70,,3.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,19.19,,1.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,50,,2.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,5.78,
HYPERBARIC OXYGEN THERAPY (:30 INCREMNT),13000277,CDM,940,RC,Q4038,HCPCS,Outpatient,,,1020,1020,,,,,,Other,Not Separately Reimbursable,841.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,841.5,82.5,,673.2,percent of total billed charges,Pays at 82.5% of total Billed charges,744.6,73,,595.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,714,70,,571.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,195.74,19.19,,156.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,510,50,,408,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,195.74,841.5,
CAST S-UP SHORT LEG FIBERGLASS,13004038,CDM,636,RC,Q4101,HCPCS,Outpatient,,,309,309,,,,,,Other,Not Separately Reimbursable,254.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,254.93,82.5,,203.944,percent of total billed charges,Pays at 82.5% of total Billed charges,225.57,73,,180.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216.3,70,,173.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.3,19.19,,47.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154.5,50,,123.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.3,254.93,
APLIGRAF PER SQ CM,13004101,CDM,636,RC,Q4102,HCPCS,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
OASIS WOUND MATRIX PER SQ CM,13004102,CDM,636,RC,Q4121,HCPCS,Outpatient,,,361,361,,,,,,Other,Not Separately Reimbursable,297.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,297.83,82.5,,238.264,percent of total billed charges,Pays at 82.5% of total Billed charges,263.53,73,,210.824,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.7,70,,202.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.28,19.19,,55.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.5,50,,144.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.28,297.83,
THERASKIN PER SQ CM,13004121,CDM,636,RC,Q4159,HCPCS,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
AFFINITY PER SQ CM,13004159,CDM,636,RC,Q4160,HCPCS,Outpatient,,,845,845,,,,,,Other,Not Separately Reimbursable,697.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,697.13,82.5,,557.704,percent of total billed charges,Pays at 82.5% of total Billed charges,616.85,73,,493.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,591.5,70,,473.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,162.16,19.19,,129.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,422.5,50,,338,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,162.16,697.13,
"NU SHIELD, PER SQ CM",13004160,CDM,636,RC,Q4195,HCPCS,Outpatient,,,1050,1050,,,,,,Other,Not Separately Reimbursable,866.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,866.25,82.5,,693,percent of total billed charges,Pays at 82.5% of total Billed charges,766.5,73,,613.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,735,70,,588,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,201.5,19.19,,161.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,525,50,,420,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,201.5,866.25,
PURAPLY ANTIMICROBIAL ANY TYPE PER SQ,13004172,CDM,636,RC,Q4186,HCPCS,Outpatient,,,558,558,,,,,,Other,Not Separately Reimbursable,460.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,460.35,82.5,,368.28,percent of total billed charges,Pays at 82.5% of total Billed charges,407.34,73,,325.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,390.6,70,,312.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.08,19.19,,85.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,279,50,,223.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.08,460.35,
"EPIFIX, PER SQUARE CM",13004186,CDM,636,RC,Q4196,HCPCS,Outpatient,,,716,716,,,,,,Other,Not Separately Reimbursable,590.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,590.7,82.5,,472.56,percent of total billed charges,Pays at 82.5% of total Billed charges,522.68,73,,418.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,501.2,70,,400.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.4,19.19,,109.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,358,50,,286.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.4,590.7,
PURAPLY ANTIMICROBIAL ANY TYPE PER SQ,13004196,CDM,636,RC,C5271,HCPCS,Outpatient,,,558,558,,,,,,Other,Not Separately Reimbursable,460.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,460.35,82.5,,368.28,percent of total billed charges,Pays at 82.5% of total Billed charges,407.34,73,,325.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,390.6,70,,312.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.08,19.19,,85.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,279,50,,223.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.08,460.35,
APPLICA LOW COST SKIN SUB TR/AR/LE 25SQ<,13005271,CDM,636,RC,C5272,HCPCS,Outpatient,,,548,548,,,,,,Other,Not Separately Reimbursable,452.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,452.1,82.5,,361.68,percent of total billed charges,Pays at 82.5% of total Billed charges,400.04,73,,320.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,383.6,70,,306.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.16,19.19,,84.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,274,50,,219.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.16,452.1,
APPLICA LOW COST SK SUB TR/AR/LE ADD 25S,13005272,CDM,636,RC,C5275,HCPCS,Outpatient,,,274,274,,,,,,Other,Not Separately Reimbursable,226.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,226.05,82.5,,180.84,percent of total billed charges,Pays at 82.5% of total Billed charges,200.02,73,,160.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191.8,70,,153.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.58,19.19,,42.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137,50,,109.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.58,226.05,
APPLICA LOW COST SKIN SUB FAC/H/FE 25SQ<,13005275,CDM,636,RC,C5276,HCPCS,Outpatient,,,548,548,,,,,,Other,Not Separately Reimbursable,452.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,452.1,82.5,,361.68,percent of total billed charges,Pays at 82.5% of total Billed charges,400.04,73,,320.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,383.6,70,,306.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.16,19.19,,84.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,274,50,,219.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.16,452.1,
APPLICA LOW COST SK SUB FA/H/FE ADD 25S,13005276,CDM,636,RC,10060,HCPCS,Outpatient,,,274,274,,,,,,Other,Not Separately Reimbursable,226.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,226.05,82.5,,180.84,percent of total billed charges,Pays at 82.5% of total Billed charges,200.02,73,,160.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191.8,70,,153.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.58,19.19,,42.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137,50,,109.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.58,226.05,
Incision and drainage of abscess; simple or single and complex or multiple,13010060,CDM,761,RC,10061,HCPCS,Outpatient,,,480,480,,,,,,Other,Not Separately Reimbursable,396,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,396,82.5,,316.8,percent of total billed charges,Pays at 82.5% of total Billed charges,350.4,73,,280.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,336,70,,268.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.11,19.19,,73.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,240,50,,192,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.11,396,
I&D ABSCESS; COMPLICATED OR MULTIPLE,13010061,CDM,761,RC,10120,HCPCS,Outpatient,,,525,525,,,,,,Other,Not Separately Reimbursable,433.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,433.13,82.5,,346.504,percent of total billed charges,Pays at 82.5% of total Billed charges,383.25,73,,306.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,367.5,70,,294,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.75,19.19,,80.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,262.5,50,,210,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.75,433.13,
INCISION & REMOVAL FOREIGN BODY SIMPLE,13010120,CDM,761,RC,10121,HCPCS,Outpatient,,,746,746,,,,,,Other,Not Separately Reimbursable,615.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,615.45,82.5,,492.36,percent of total billed charges,Pays at 82.5% of total Billed charges,544.58,73,,435.664,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,522.2,70,,417.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.16,19.19,,114.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,373,50,,298.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.16,615.45,
I&D REMOVAL FB COMPLEX,13010121,CDM,761,RC,10140,HCPCS,Outpatient,,,2686,2686,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1960.78,73,,1568.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1880.2,70,,1504.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,515.44,19.19,,412.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1343,50,,1074.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,515.44,1960.78,
"Incision and drainage of hematoma, seroma or fluid collection",13010140,CDM,761,RC,10160,HCPCS,Outpatient,,,1555,1555,,,,,,Other,Not Separately Reimbursable,1282.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1282.88,82.5,,1026.304,percent of total billed charges,Pays at 82.5% of total Billed charges,1135.15,73,,908.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1088.5,70,,870.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,298.4,19.19,,238.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,777.5,50,,622,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,298.4,1282.88,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",13010160,CDM,761,RC,11000,HCPCS,Outpatient,,,737,737,,,,,,Other,Not Separately Reimbursable,608.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,608.03,82.5,,486.424,percent of total billed charges,Pays at 82.5% of total Billed charges,538.01,73,,430.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,515.9,70,,412.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,141.43,19.19,,113.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,368.5,50,,294.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,141.43,608.03,
Removal of infected skin,13011000,CDM,761,RC,11042,HCPCS,Outpatient,,,746,746,,,,,,Other,Not Separately Reimbursable,615.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,615.45,82.5,,492.36,percent of total billed charges,Pays at 82.5% of total Billed charges,544.58,73,,435.664,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,522.2,70,,417.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.16,19.19,,114.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,373,50,,298.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.16,615.45,
WOUND DEBRIDEMENT (FULL THICKNESS),13011041,CDM,761,RC,11042,HCPCS,Outpatient,,,510,510,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,372.3,73,,297.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,357,70,,285.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,19.19,,78.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255,50,,204,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,1319.85,
WOUND DEBRIDEMENT (SUBQ & TISSUE),13011042,CDM,761,RC,11043,HCPCS,Outpatient,,,510,510,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,372.3,73,,297.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,357,70,,285.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,19.19,,78.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,255,50,,204,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.87,1319.85,
WOUND DEBRIDEMENT (TISSUE & MUSCLE),13011043,CDM,761,RC,11044,HCPCS,Outpatient,,,746,746,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,544.58,73,,435.664,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,522.2,70,,417.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.16,19.19,,114.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,373,50,,298.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.16,1319.85,
"WOUND DEBRIDEMENT (SUBQ,TISSUE, MSCL,BO)",13011044,CDM,761,RC,11045,HCPCS,Outpatient,,,2183,2183,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1593.59,73,,1274.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1528.1,70,,1222.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,418.92,19.19,,335.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1091.5,50,,873.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,418.92,1593.59,
"EXC/DEB SUBQ TISSUE ADD 20 SQCM, OR PART",13011045,CDM,761,RC,11046,HCPCS,Outpatient,,,614,614,,,,,,Other,Not Separately Reimbursable,506.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,506.55,82.5,,405.24,percent of total billed charges,Pays at 82.5% of total Billed charges,448.22,73,,358.576,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,429.8,70,,343.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.83,19.19,,94.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,307,50,,245.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.83,506.55,
WND DEBRID(TISSUE& MUSCLE)EA ADDL 20SQCM,13011046,CDM,761,RC,11047,HCPCS,Outpatient,,,746,746,,,,,,Other,Not Separately Reimbursable,615.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,615.45,82.5,,492.36,percent of total billed charges,Pays at 82.5% of total Billed charges,544.58,73,,435.664,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,522.2,70,,417.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.16,19.19,,114.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,373,50,,298.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.16,615.45,
"WND DEBRID(BONE,TIS, MUS)EA ADD 20SQCM",13011047,CDM,761,RC,11055,HCPCS,Outpatient,,,800,800,,,,,,Other,Not Separately Reimbursable,660,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,660,82.5,,528,percent of total billed charges,Pays at 82.5% of total Billed charges,584,73,,467.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,560,70,,448,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153.52,19.19,,122.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,400,50,,320,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153.52,660,
BENIGN LESION PARING,13011055,CDM,761,RC,11056,HCPCS,Outpatient,,,248,248,,,,,,Other,Not Separately Reimbursable,204.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,204.6,82.5,,163.68,percent of total billed charges,Pays at 82.5% of total Billed charges,181.04,73,,144.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,173.6,70,,138.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.59,19.19,,38.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124,50,,99.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.59,204.6,
Paring or cutting of benign hyperkeratotic lesion,13011056,CDM,761,RC,11100,HCPCS,Outpatient,,,205,205,,,,,,Other,Not Separately Reimbursable,169.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,169.13,82.5,,135.304,percent of total billed charges,Pays at 82.5% of total Billed charges,149.65,73,,119.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.5,70,,114.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,19.19,,31.472,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.5,50,,82,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,169.13,
BIOPSY SKIN SUBQ,13011100,CDM,761,RC,11102,HCPCS,Outpatient,,,409,409,,,,,,Other,Not Separately Reimbursable,337.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,337.43,82.5,,269.944,percent of total billed charges,Pays at 82.5% of total Billed charges,298.57,73,,238.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,286.3,70,,229.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.49,19.19,,62.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,204.5,50,,163.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.49,337.43,
"Tangential biopsy of skin (e.g., for example, shave, scoop, saucerize, curette); single lesion",13011102,CDM,761,RC,11103,HCPCS,Outpatient,,,409,409,,,,,,Other,Not Separately Reimbursable,337.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,337.43,82.5,,269.944,percent of total billed charges,Pays at 82.5% of total Billed charges,298.57,73,,238.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,286.3,70,,229.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.49,19.19,,62.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,204.5,50,,163.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.49,337.43,
"Tangential biopsy of skin (e.g., for example, shave, scoop, saucerize, curette); each separate/additional lesion",13011103,CDM,761,RC,11104,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
PUNCH BX OF SKIN; SINGLE LESION,13011104,CDM,761,RC,11105,HCPCS,Outpatient,,,409,409,,,,,,Other,Not Separately Reimbursable,337.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,337.43,82.5,,269.944,percent of total billed charges,Pays at 82.5% of total Billed charges,298.57,73,,238.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,286.3,70,,229.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.49,19.19,,62.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,204.5,50,,163.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.49,337.43,
PUNCH BX OF SKIN; SNGLE LES EA ADDL,13011105,CDM,761,RC,11106,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
INCISIONAL BX OF SKIN; SINGLE LESION,13011106,CDM,761,RC,11107,HCPCS,Outpatient,,,409,409,,,,,,Other,Not Separately Reimbursable,337.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,337.43,82.5,,269.944,percent of total billed charges,Pays at 82.5% of total Billed charges,298.57,73,,238.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,286.3,70,,229.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.49,19.19,,62.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,204.5,50,,163.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.49,337.43,
INCISIONAL BX OF SKIN SNGL LESION EA ADD,13011107,CDM,761,RC,11400,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,62.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,62.7,82.5,,50.16,percent of total billed charges,Pays at 82.5% of total Billed charges,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,62.7,
BENIGN SKIN LESION REM .5 CM OR LESS,13011400,CDM,761,RC,11401,HCPCS,Outpatient,,,654,654,,,,,,Other,Not Separately Reimbursable,539.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,539.55,82.5,,431.64,percent of total billed charges,Pays at 82.5% of total Billed charges,477.42,73,,381.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,457.8,70,,366.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125.5,19.19,,100.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,327,50,,261.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125.5,539.55,
Under Excision-Benign Lesions Procedures on the Skin 0.6-1 CM,13011401,CDM,761,RC,11402,HCPCS,Outpatient,,,654,654,,,,,,Other,Not Separately Reimbursable,539.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,539.55,82.5,,431.64,percent of total billed charges,Pays at 82.5% of total Billed charges,477.42,73,,381.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,457.8,70,,366.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125.5,19.19,,100.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,327,50,,261.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125.5,539.55,
BENIGN SKIN LESION REM 1.1 - 2.0 CM,13011402,CDM,761,RC,11421,HCPCS,Outpatient,,,654,654,,,,,,Other,Not Separately Reimbursable,539.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,539.55,82.5,,431.64,percent of total billed charges,Pays at 82.5% of total Billed charges,477.42,73,,381.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,457.8,70,,366.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125.5,19.19,,100.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,327,50,,261.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125.5,539.55,
EXC BEN LESION S/N/H/F/G .6 TO 1.0CM,13011421,CDM,761,RC,11601,HCPCS,Outpatient,,,1348,1348,,,,,,Other,Not Separately Reimbursable,1112.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1112.1,82.5,,889.68,percent of total billed charges,Pays at 82.5% of total Billed charges,984.04,73,,787.232,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,943.6,70,,754.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,258.68,19.19,,206.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,674,50,,539.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,258.68,1112.1,
EXC MAL LESION T/A/L .6 TO 1.0CM,13011601,CDM,761,RC,11602,HCPCS,Outpatient,,,1719,1719,,,,,,Other,Not Separately Reimbursable,1418.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1418.18,82.5,,1134.544,percent of total billed charges,Pays at 82.5% of total Billed charges,1254.87,73,,1003.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1203.3,70,,962.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329.88,19.19,,263.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,859.5,50,,687.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329.88,1418.18,
Excision-Malignant Lesions,13011602,CDM,761,RC,11603,HCPCS,Outpatient,,,1144,1144,,,,,,Other,Not Separately Reimbursable,943.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,943.8,82.5,,755.04,percent of total billed charges,Pays at 82.5% of total Billed charges,835.12,73,,668.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,800.8,70,,640.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,219.53,19.19,,175.624,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,572,50,,457.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,219.53,943.8,
"EXC MALIG INC MARGINS;TR,ARM,LEG 2.1-3CM",13011603,CDM,761,RC,11604,HCPCS,Outpatient,,,1719,1719,,,,,,Other,Not Separately Reimbursable,1418.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1418.18,82.5,,1134.544,percent of total billed charges,Pays at 82.5% of total Billed charges,1254.87,73,,1003.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1203.3,70,,962.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329.88,19.19,,263.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,859.5,50,,687.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329.88,1418.18,
"EXC MALIG INC MARGINS;TR,ARM,LEG 3.1-4CM",13011604,CDM,761,RC,11621,HCPCS,Outpatient,,,1719,1719,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1254.87,73,,1003.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1203.3,70,,962.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329.88,19.19,,263.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,859.5,50,,687.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329.88,1319.85,
EXCIS MALIG LESION SC/NE/HA/FE/G.5-1.0CM,13011621,CDM,761,RC,11719,HCPCS,Outpatient,,,1719,1719,,,,,,Other,Not Separately Reimbursable,1418.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1418.18,82.5,,1134.544,percent of total billed charges,Pays at 82.5% of total Billed charges,1254.87,73,,1003.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1203.3,70,,962.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329.88,19.19,,263.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,859.5,50,,687.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329.88,1418.18,
TRIMMING OF NONDYSTROPHIC NAILS (ANY #),13011719,CDM,761,RC,11720,HCPCS,Outpatient,,,118,118,,,,,,Other,Not Separately Reimbursable,97.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,97.35,82.5,,77.88,percent of total billed charges,Pays at 82.5% of total Billed charges,86.14,73,,68.912,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.6,70,,66.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,19.19,,18.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59,50,,47.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,97.35,
DEBRIDEMENT OF NAILS (1-5),13011720,CDM,761,RC,11730,HCPCS,Outpatient,,,248,248,,,,,,Other,Not Separately Reimbursable,204.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,204.6,82.5,,163.68,percent of total billed charges,Pays at 82.5% of total Billed charges,181.04,73,,144.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,173.6,70,,138.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.59,19.19,,38.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124,50,,99.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.59,204.6,
Separation and removal of the entire nail plate or a portion of nail plate,13011730,CDM,761,RC,11770,HCPCS,Outpatient,,,205,205,,,,,,Other,Not Separately Reimbursable,169.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,169.13,82.5,,135.304,percent of total billed charges,Pays at 82.5% of total Billed charges,149.65,73,,119.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.5,70,,114.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,19.19,,31.472,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.5,50,,82,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,169.13,
EXCIS OF PILONIDAL CYST OR SINUS;SIMPLE,13011770,CDM,761,RC,12001,HCPCS,Outpatient,,,5218,5218,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,3809.14,73,,3047.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3652.6,70,,2922.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1001.33,19.19,,801.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2609,50,,2087.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1001.33,3809.14,
"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",13012001,CDM,761,RC,12002,HCPCS,Outpatient,,,300,300,,,,,,Other,Not Separately Reimbursable,247.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,247.5,82.5,,198,percent of total billed charges,Pays at 82.5% of total Billed charges,219,73,,175.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,210,70,,168,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.57,19.19,,46.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,150,50,,120,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.57,247.5,
SIM RPR SUPERFICIAL WND 2.6-7.5 CM,13012002,CDM,761,RC,12031,HCPCS,Outpatient,,,300,300,,,,,,Other,Not Separately Reimbursable,247.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,247.5,82.5,,198,percent of total billed charges,Pays at 82.5% of total Billed charges,219,73,,175.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,210,70,,168,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.57,19.19,,46.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,150,50,,120,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.57,247.5,
INTMD WD REPAIR S/TR/EXT 2.5 CM OR LESS,13012031,CDM,761,RC,12032,HCPCS,Outpatient,,,194,194,,,,,,Other,Not Separately Reimbursable,160.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,160.05,82.5,,128.04,percent of total billed charges,Pays at 82.5% of total Billed charges,141.62,73,,113.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,135.8,70,,108.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.23,19.19,,29.784,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97,50,,77.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.23,160.05,
INTMD WD REPAIR S/TR/EXT 2.6-7.5 CM,13012032,CDM,761,RC,15002,HCPCS,Outpatient,,,407,407,,,,,,Other,Not Separately Reimbursable,335.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,335.78,82.5,,268.624,percent of total billed charges,Pays at 82.5% of total Billed charges,297.11,73,,237.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,284.9,70,,227.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.1,19.19,,62.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.5,50,,162.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.1,335.78,
"SUR PREP EXC OF OPEN WND,BURN SCAR 100SQ",13015002,CDM,761,RC,15004,HCPCS,Outpatient,,,4705,4705,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,3434.65,73,,2747.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3293.5,70,,2634.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,902.89,19.19,,722.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2352.5,50,,1882,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,902.89,3434.65,
"SUR PREP EXC OF OPEN WND,BURN SCAR 100SQ",13015004,CDM,761,RC,15110,HCPCS,Outpatient,,,1465,1465,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1069.45,73,,855.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1025.5,70,,820.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,281.13,19.19,,224.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,732.5,50,,586,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,281.13,1319.85,
EPIDERMIC AUTOGRF TRK/ARM/LG <=100SQCM,13015110,CDM,761,RC,15111,HCPCS,Outpatient,,,1920,1920,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1401.6,73,,1121.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1344,70,,1075.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,368.45,19.19,,294.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,960,50,,768,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,368.45,1401.6,
EPIDERMIC AUTOGRF TRK/ARM/LG/ EA+100SQCM,13015111,CDM,761,RC,15115,HCPCS,Outpatient,,,289,289,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,210.97,73,,168.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,202.3,70,,161.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.46,19.19,,44.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.5,50,,115.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.46,982.8,
"EPIDERMIC AUTOGRF,F/S/E/M/N/E/ <=100SQCM",13015115,CDM,761,RC,15116,HCPCS,Outpatient,,,1976,1976,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1442.48,73,,1153.984,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1383.2,70,,1106.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,379.19,19.19,,303.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,988,50,,790.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,379.19,1442.48,
"EPIDERMIC AUTOGRF,F/S/E/M/N/E EA+100SQCM",13015116,CDM,761,RC,15271,HCPCS,Outpatient,,,382,382,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,278.86,73,,223.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,267.4,70,,213.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.31,19.19,,58.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191,50,,152.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.31,982.8,
SK SUBGRAFT TRNK/ARM/LEG FIRST 25 SQCM<,13015271,CDM,761,RC,15272,HCPCS,Outpatient,,,255,255,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,186.15,73,,148.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,178.5,70,,142.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.93,19.19,,39.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,127.5,50,,102,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.93,1319.85,
SK SUBGRAFT TRNK/ARM/LEG EA ADD 25 SQCM,13015272,CDM,761,RC,15273,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,1319.85,
APPL SKINGRAFT TRK/A/L 1ST 100 SQCM,13015273,CDM,761,RC,15274,HCPCS,Outpatient,,,608,608,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,443.84,73,,355.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,425.6,70,,340.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.68,19.19,,93.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,304,50,,243.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.68,1319.85,
APPL SKINGRAFT TRK/A/L EA ADD 100 SQCM,13015274,CDM,761,RC,15275,HCPCS,Outpatient,,,129,129,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,94.17,73,,75.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.3,70,,72.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.76,19.19,,19.808,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.5,50,,51.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.76,1319.85,
SK SUBGRAFT FACE/NK/HF/G FIRST 25 SQCM <,13015275,CDM,761,RC,15276,HCPCS,Outpatient,,,296,296,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,216.08,73,,172.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,207.2,70,,165.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.8,19.19,,45.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148,50,,118.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.8,1319.85,
SK SUBGRAFT FACE/NK/HF/G EA AD 25 SQCM,13015276,CDM,761,RC,16020,HCPCS,Outpatient,,,72,72,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,52.56,73,,42.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.4,70,,40.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,19.19,,11.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36,50,,28.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,1319.85,
"TX OF BURNS W/O ANESTHESIA, SMALL",13016020,CDM,761,RC,16025,HCPCS,Outpatient,,,242,242,,,,,,Other,Not Separately Reimbursable,199.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,199.65,82.5,,159.72,percent of total billed charges,Pays at 82.5% of total Billed charges,176.66,73,,141.328,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,169.4,70,,135.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.44,19.19,,37.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121,50,,96.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.44,199.65,
"TX OF BURNS W/O ANESTHESIA, MEDIUM",13016025,CDM,761,RC,16030,HCPCS,Outpatient,,,409,409,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,298.57,73,,238.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,286.3,70,,229.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.49,19.19,,62.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,204.5,50,,163.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.49,1319.85,
"TX OF BURNS W/O ANESTHESIA, LARGE",13016030,CDM,761,RC,16035,HCPCS,Outpatient,,,409,409,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,298.57,73,,238.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,286.3,70,,229.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.49,19.19,,62.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,204.5,50,,163.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.49,982.8,
ESCHAROTOMY; INITIAL INCISION,13016035,CDM,761,RC,17250,HCPCS,Outpatient,,,932,932,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,680.36,73,,544.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,652.4,70,,521.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,178.85,19.19,,143.08,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,466,50,,372.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,178.85,1319.85,
Chemical destruction of pre-cancerous lesions of the skin,13017250,CDM,761,RC,20205,HCPCS,Outpatient,,,194,194,,,,,,Other,Not Separately Reimbursable,160.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,160.05,82.5,,128.04,percent of total billed charges,Pays at 82.5% of total Billed charges,141.62,73,,113.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,135.8,70,,108.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.23,19.19,,29.784,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97,50,,77.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.23,160.05,
"BIOPSY, MUSCLE; DEEP",13020205,CDM,761,RC,20225,HCPCS,Outpatient,,,4066,4066,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,2968.18,73,,2374.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2846.2,70,,2276.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,780.27,19.19,,624.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2033,50,,1626.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,780.27,2968.18,
"BIOPSY, BONE,TROCAR/NEEDLE; DEEP",13020225,CDM,761,RC,20240,HCPCS,Outpatient,,,308,308,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,224.84,73,,179.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,215.6,70,,172.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.11,19.19,,47.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154,50,,123.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.11,1319.85,
BIOPSY BONE OPEN;SUPERFICIAL,13020240,CDM,761,RC,27324,HCPCS,Outpatient,,,401,401,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,292.73,73,,234.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280.7,70,,224.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.95,19.19,,61.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,200.5,50,,160.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.95,1319.85,
BIOPSY SOFT TISSUE THIGH/KNEE DEEP,13027324,CDM,761,RC,27613,HCPCS,Outpatient,,,5375,5375,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,3923.75,73,,3139,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3762.5,70,,3010,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1031.46,19.19,,825.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2687.5,50,,2150,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,982.8,3923.75,
BIOPSY SFT TISSUE LEG/ANKLE;SUPERFICAL,13027613,CDM,761,RC,28190,HCPCS,Outpatient,,,2183,2183,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1593.59,73,,1274.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1528.1,70,,1222.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,418.92,19.19,,335.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1091.5,50,,873.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,418.92,1593.59,
"REMOVAL OF FOREIGN BODY,FOOT;SUBCUTANEOU",13028190,CDM,761,RC,28810,HCPCS,Outpatient,,,1719,1719,,,,,,Other,Not Separately Reimbursable,1418.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1418.18,82.5,,1134.544,percent of total billed charges,Pays at 82.5% of total Billed charges,1254.87,73,,1003.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1203.3,70,,962.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329.88,19.19,,263.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,859.5,50,,687.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329.88,1418.18,
"AMPUTATION, METATARSAL, WITH TOE, SINGLE",13028810,CDM,761,RC,28820,HCPCS,Outpatient,,,2645,2645,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1930.85,73,,1544.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1851.5,70,,1481.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,507.58,19.19,,406.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1322.5,50,,1058,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,507.58,1930.85,
AMPUTATION TOE; METATARSOPHALANGEAL JOIN,13028820,CDM,761,RC,29445,HCPCS,Outpatient,,,5082,5082,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,3709.86,73,,2967.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3557.4,70,,2845.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,975.24,19.19,,780.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2541,50,,2032.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,975.24,3709.86,
APPLY RIGID TOTAL CONTACT LEG CAST,13029445,CDM,761,RC,29580,HCPCS,Outpatient,,,654,654,,,,,,Other,Not Separately Reimbursable,539.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,539.55,82.5,,431.64,percent of total billed charges,Pays at 82.5% of total Billed charges,477.42,73,,381.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,457.8,70,,366.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125.5,19.19,,100.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,327,50,,261.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125.5,539.55,
APPLICATION OF PASTE/UNNA BOOT,13029580,CDM,761,RC,29581,HCPCS,Outpatient,,,214,214,,,,,,Other,Not Separately Reimbursable,176.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,176.55,82.5,,141.24,percent of total billed charges,Pays at 82.5% of total Billed charges,156.22,73,,124.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.8,70,,119.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.07,19.19,,32.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107,50,,85.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.07,176.55,
APPLY MULTI-LAYER COMPRESSION LOWER LEG,13029581,CDM,761,RC,36589,HCPCS,Outpatient,,,306,306,,,,,,Other,Not Separately Reimbursable,252.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,252.45,82.5,,201.96,percent of total billed charges,Pays at 82.5% of total Billed charges,223.38,73,,178.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.2,70,,171.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,19.19,,46.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153,50,,122.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,252.45,
REM TUNNELED CENT VENOUS CATH W/OUT SUB,13036589,CDM,761,RC,38220,HCPCS,Outpatient,,,407,407,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,297.11,73,,237.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,284.9,70,,227.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.1,19.19,,62.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.5,50,,162.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.1,982.8,
BONE MARROW; ASPIRATION ONLY,13038220,CDM,761,RC,38221,HCPCS,Outpatient,,,961,961,,,,,,Other,Not Separately Reimbursable,792.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,792.83,82.5,,634.264,percent of total billed charges,Pays at 82.5% of total Billed charges,701.53,73,,561.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,672.7,70,,538.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,184.42,19.19,,147.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,480.5,50,,384.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,184.42,792.83,
"BONE MARROW BIOPSY, NEEDLE OR TROCAR",13038221,CDM,761,RC,43762,HCPCS,Outpatient,,,961,961,,,,,,Other,Not Separately Reimbursable,792.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,792.83,82.5,,634.264,percent of total billed charges,Pays at 82.5% of total Billed charges,701.53,73,,561.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,672.7,70,,538.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,184.42,19.19,,147.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,480.5,50,,384.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,184.42,792.83,
REPLACE GASTR TUBE PERCUT W/O IMAG/REVIS,13043762,CDM,450,RC,51702,HCPCS,Outpatient,,,496,496,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,362.08,73,,289.664,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,347.2,70,,277.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.18,19.19,,76.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,248,50,,198.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.18,982.8,
INS OF FOLEY CATHETER,13051702,CDM,761,RC,69420,HCPCS,Outpatient,,,183,183,,,,,,Other,Not Separately Reimbursable,150.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,150.98,82.5,,120.784,percent of total billed charges,Pays at 82.5% of total Billed charges,133.59,73,,106.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.1,70,,102.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.12,19.19,,28.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.5,50,,73.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.12,150.98,
MYRINGOTOMY INC ASPIRATION/EUSTACHIAN TU,13069420,CDM,761,RC,69433,HCPCS,Outpatient,,,353,353,,,,,,Other,Not Separately Reimbursable,291.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,291.23,82.5,,232.984,percent of total billed charges,Pays at 82.5% of total Billed charges,257.69,73,,206.152,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,247.1,70,,197.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.74,19.19,,54.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.5,50,,141.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.74,291.23,
"TYMPANOSTOMY, LOCAL/TOPICAL ANESTHESIA",13069433,CDM,761,RC,93923,HCPCS,Outpatient,,,2035,2035,,,,,,Other,Not Separately Reimbursable,1678.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1678.88,82.5,,1343.104,percent of total billed charges,Pays at 82.5% of total Billed charges,1485.55,73,,1188.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1424.5,70,,1139.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,390.52,19.19,,312.416,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1017.5,50,,814,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,390.52,1678.88,
NONINVASIVE ARTERIAL STUDY (MULT LVLS),13093923,CDM,761,RC,97597,HCPCS,Outpatient,,,1008,1008,,,,,,Other,Not Separately Reimbursable,248.63,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,248.63,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,735.84,73,,588.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,705.6,70,,564.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,193.44,19.19,,154.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,504,50,,403.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,193.44,735.84,
"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",13097597,CDM,761,RC,97598,HCPCS,Outpatient,,,216,216,,,,,,Other,Not Separately Reimbursable,178.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,178.2,82.5,,142.56,percent of total billed charges,Pays at 82.5% of total Billed charges,157.68,73,,126.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.2,70,,120.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.45,19.19,,33.16,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108,50,,86.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.45,178.2,
ACTIVE WOUND CARE > 20 CM,13097598,CDM,761,RC,97602,HCPCS,Outpatient,,,216,216,,,,,,Other,Not Separately Reimbursable,178.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,178.2,82.5,,142.56,percent of total billed charges,Pays at 82.5% of total Billed charges,157.68,73,,126.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.2,70,,120.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.45,19.19,,33.16,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108,50,,86.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.45,178.2,
ACTIVE WOUND CARE NON-SELECTIVE,13097602,CDM,761,RC,97605,HCPCS,Outpatient,,,890,890,,,,,,Other,Not Separately Reimbursable,734.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,734.25,82.5,,587.4,percent of total billed charges,Pays at 82.5% of total Billed charges,649.7,73,,519.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,623,70,,498.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,19.19,,136.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,445,50,,356,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,734.25,
NEG PRESSURE WOUND TX <50CM,13097605,CDM,761,RC,97606,HCPCS,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
NEG PRESSURE WOUND TX >50CM,13097606,CDM,761,RC,97607,HCPCS,Outpatient,,,216,216,,,,,,Other,Not Separately Reimbursable,178.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,178.2,82.5,,142.56,percent of total billed charges,Pays at 82.5% of total Billed charges,157.68,73,,126.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.2,70,,120.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.45,19.19,,33.16,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108,50,,86.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.45,178.2,
NEG PRESS WND THER SNAP;TOTAL WND <50CM2,13097607,CDM,761,RC,97608,HCPCS,Outpatient,,,825,825,,,,,,Other,Not Separately Reimbursable,680.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,680.63,82.5,,544.504,percent of total billed charges,Pays at 82.5% of total Billed charges,602.25,73,,481.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,577.5,70,,462,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,158.32,19.19,,126.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,412.5,50,,330,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,158.32,680.63,
NEG PRESS WND THER SNAP;TOTAL WND >50CM2,13097608,CDM,761,RC,99201,HCPCS,Outpatient,,,1225,1225,,,,,,Other,Not Separately Reimbursable,1010.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1010.63,82.5,,808.504,percent of total billed charges,Pays at 82.5% of total Billed charges,894.25,73,,715.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,857.5,70,,686,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,235.08,19.19,,188.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,612.5,50,,490,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,235.08,1010.63,
NEW OP VISIT (BRIEF) 15 MIN,13099201,CDM,761,RC,99202,HCPCS,Outpatient,,,188,188,,,,,,Other,Not Separately Reimbursable,155.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,155.1,82.5,,124.08,percent of total billed charges,Pays at 82.5% of total Billed charges,137.24,73,,109.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,131.6,70,,105.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.08,19.19,,28.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94,50,,75.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.08,155.1,
"New patient office or other outpatient visit, typically 10 minutes",13099202,CDM,761,RC,99203,HCPCS,Outpatient,,,227,227,,,,,,Other,Not Separately Reimbursable,187.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,187.28,82.5,,149.824,percent of total billed charges,Pays at 82.5% of total Billed charges,165.71,73,,132.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,158.9,70,,127.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.56,19.19,,34.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,113.5,50,,90.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.56,187.28,
"New patient office or other outpatient visit, typically 30 min",13099203,CDM,761,RC,99204,HCPCS,Outpatient,,,290,290,,,,,,Other,Not Separately Reimbursable,239.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,239.25,82.5,,191.4,percent of total billed charges,Pays at 82.5% of total Billed charges,211.7,73,,169.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203,70,,162.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.65,19.19,,44.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,145,50,,116,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.65,239.25,
"New patient office of other outpatient visit, typically 45 min",13099204,CDM,761,RC,99205,HCPCS,Outpatient,,,370,370,,,,,,Other,Not Separately Reimbursable,305.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,305.25,82.5,,244.2,percent of total billed charges,Pays at 82.5% of total Billed charges,270.1,73,,216.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,259,70,,207.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,19.19,,56.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,185,50,,148,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,305.25,
"New patient office of other outpatient visit, typically 60 min",13099205,CDM,761,RC,99211,HCPCS,Outpatient,,,546,546,,,,,,Other,Not Separately Reimbursable,450.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,450.45,82.5,,360.36,percent of total billed charges,Pays at 82.5% of total Billed charges,398.58,73,,318.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,382.2,70,,305.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.78,19.19,,83.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,273,50,,218.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.78,450.45,
Outpatient visit of established patient not requiring a physician,13099211,CDM,761,RC,99212,HCPCS,Outpatient,,,188,188,,,,,,Other,Not Separately Reimbursable,155.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,155.1,82.5,,124.08,percent of total billed charges,Pays at 82.5% of total Billed charges,137.24,73,,109.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,131.6,70,,105.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.08,19.19,,28.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94,50,,75.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.08,155.1,
Outpatient visit of established patient requiring a physician,13099212,CDM,761,RC,99213,HCPCS,Outpatient,,,227,227,,,,,,Other,Not Separately Reimbursable,187.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,187.28,82.5,,149.824,percent of total billed charges,Pays at 82.5% of total Billed charges,165.71,73,,132.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,158.9,70,,127.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.56,19.19,,34.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,113.5,50,,90.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.56,187.28,
"Established patient office or other outpatient visit, typically 15 minutes",13099213,CDM,761,RC,99214,HCPCS,Outpatient,,,257,257,,,,,,Other,Not Separately Reimbursable,212.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,212.03,82.5,,169.624,percent of total billed charges,Pays at 82.5% of total Billed charges,187.61,73,,150.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.9,70,,143.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.32,19.19,,39.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.5,50,,102.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.32,212.03,
"Established patient office or other outpatient visit, typically 25 minutes",13099214,CDM,761,RC,99215,HCPCS,Outpatient,,,290,290,,,,,,Other,Not Separately Reimbursable,239.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,239.25,82.5,,191.4,percent of total billed charges,Pays at 82.5% of total Billed charges,211.7,73,,169.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203,70,,162.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.65,19.19,,44.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,145,50,,116,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.65,239.25,
"Established patient office or other outpatient, visit typically 40 minutes",13099215,CDM,761,RC,97602,HCPCS,Outpatient,,,370,370,,,,,,Other,Not Separately Reimbursable,305.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,305.25,82.5,,244.2,percent of total billed charges,Pays at 82.5% of total Billed charges,270.1,73,,216.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,259,70,,207.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,19.19,,56.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,185,50,,148,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,305.25,
MAGGOT THERAPY-ACTIVE WND CARE NON-SELEC,13197602,CDM,761,RC,83918,HCPCS,Outpatient,,,890,890,,,,,,Other,Not Separately Reimbursable,734.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,734.25,82.5,,587.4,percent of total billed charges,Pays at 82.5% of total Billed charges,649.7,73,,519.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,623,70,,498.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,19.19,,136.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,445,50,,356,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,734.25,
"ORGANIC ACID SCREEN, URINE",14030001,CDM,301,RC,80299,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
"PEMOLINE,(CYLERT)",14030002,CDM,301,RC,82379,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
CARNITINE,14030003,CDM,301,RC,88248,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
"CHROMOSOME ANALYS,BLD",14030004,CDM,310,RC,82128,HCPCS,Outpatient,,,593,593,,,,,,Other,Not Separately Reimbursable,489.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,489.23,82.5,,391.384,percent of total billed charges,Pays at 82.5% of total Billed charges,432.89,73,,346.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,415.1,70,,332.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,113.8,19.19,,91.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,296.5,50,,237.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,113.8,489.23,
AMINO ACID PROF URINE,14030005,CDM,301,RC,82441,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
PCB/CHLORINATED PESTICIDE EXPOSURE PANEL,14030006,CDM,301,RC,84210,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
"PYRUVIC ACID, BLOOD",14030007,CDM,301,RC,86255,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
STRIATIONAL ANTIBODIES,14030008,CDM,302,RC,86148,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
PHOSPHATIDYLSERINE ABS,14030009,CDM,302,RC,82726,HCPCS,Outpatient,,,68,68,,,,,,Other,Not Separately Reimbursable,56.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.1,82.5,,44.88,percent of total billed charges,Pays at 82.5% of total Billed charges,49.64,73,,39.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.6,70,,38.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,19.19,,10.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34,50,,27.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,56.1,
PEROXISOMAL DISORDER PANEL,14030010,CDM,301,RC,84182,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
YO (PURKINJE) ANTIBODY,14030011,CDM,301,RC,83520,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,62.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,62.7,82.5,,50.16,percent of total billed charges,Pays at 82.5% of total Billed charges,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,62.7,
ANTI-NEURONAL/HU AUTOANTIBODY,14030012,CDM,301,RC,85240,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
von WILLEBRAND PROFILE with MULTIMERS,14030013,CDM,305,RC,80201,HCPCS,Outpatient,,,122,122,,,,,,Other,Not Separately Reimbursable,100.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,100.65,82.5,,80.52,percent of total billed charges,Pays at 82.5% of total Billed charges,89.06,73,,71.248,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85.4,70,,68.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.41,19.19,,18.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61,50,,48.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.41,100.65,
"TOPIRAMATE(TOPAMAX),SERUM",14030014,CDM,301,RC,82668,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
"ERYTHROPOIETIN, SERUM",14030015,CDM,301,RC,80197,HCPCS,Outpatient,,,79,79,,,,,,Other,Not Separately Reimbursable,65.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,65.18,82.5,,52.144,percent of total billed charges,Pays at 82.5% of total Billed charges,57.67,73,,46.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.3,70,,44.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,19.19,,12.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.5,50,,31.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,65.18,
"TACROLIMUS, BLOOD",14030016,CDM,301,RC,84153,HCPCS,Outpatient,,,180,180,,,,,,Other,Not Separately Reimbursable,148.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,148.5,82.5,,118.8,percent of total billed charges,Pays at 82.5% of total Billed charges,131.4,73,,105.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126,70,,100.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,19.19,,27.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90,50,,72,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,148.5,
PSA (prostate specific antigen),14030017,CDM,301,RC,82248,HCPCS,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,82.25,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,82.25,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,82.25,
Measurement of direct bilirubin,14030018,CDM,301,RC,85660,HCPCS,Outpatient,,,69,69,,,,,,Other,Not Separately Reimbursable,21.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,21.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,50.37,73,,40.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.3,70,,38.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.24,19.19,,10.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,50,,27.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.24,50.37,
SICKLE CELL SCREEN,14030019,CDM,305,RC,86171,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
CAT SCRATCH ANTIBODY,14030020,CDM,302,RC,88248,HCPCS,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
HIGH RESOLUTION CHROMOSOME ANALYSIS,14030022,CDM,310,RC,85025,HCPCS,Outpatient,,,593,593,,,,,,Other,Not Separately Reimbursable,489.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,489.23,82.5,,391.384,percent of total billed charges,Pays at 82.5% of total Billed charges,432.89,73,,346.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,415.1,70,,332.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,113.8,19.19,,91.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,296.5,50,,237.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,113.8,489.23,
"Complete blood cell count, with differential white blood cells, automated",14030023,CDM,305,RC,,,Outpatient,,,135,135,,,,,,Other,Not Separately Reimbursable,34.78,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,34.78,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,98.55,73,,78.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.5,70,,75.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.91,19.19,,20.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.5,50,,54,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.91,98.55,
"VET DIFFERENTIAL,MANUAL",14030024,CDM,305,RC,82017,HCPCS,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
ACYLCARNITINE PANEL,14030025,CDM,301,RC,83698,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
LIPOPROTEIN ASSOC PHOSPHOLIPASE A2,14030026,CDM,302,RC,82776,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
COMPREHENSIVE NEWBORN SCREEN,14030027,CDM,301,RC,83021,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,28.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.88,82.5,,23.104,percent of total billed charges,Pays at 82.5% of total Billed charges,25.55,73,,20.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,70,,19.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,19.19,,5.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,50,,14,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,28.88,
HEMOGLOBIN VAR. REFLEX TO ELECTROPH.,14030028,CDM,302,RC,86343,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
FUNCTIONAL ANTI-FCER AUTOANTIBODY,14030029,CDM,302,RC,80299,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,43.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,43.73,82.5,,34.984,percent of total billed charges,Pays at 82.5% of total Billed charges,38.69,73,,30.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.1,70,,29.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,19.19,,8.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.5,50,,21.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,43.73,
MYCOPHENOLIC ACID,14030030,CDM,301,RC,88230,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
BECKWITH-WIEDMANN SYNDROME BY FISH,14030031,CDM,310,RC,82380,HCPCS,Outpatient,,,399,399,,,,,,Other,Not Separately Reimbursable,329.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,329.18,82.5,,263.344,percent of total billed charges,Pays at 82.5% of total Billed charges,291.27,73,,233.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,279.3,70,,223.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.57,19.19,,61.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,199.5,50,,159.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.57,329.18,
"CAROTENES, FRACTIONATED",14030033,CDM,301,RC,82726,HCPCS,Outpatient,,,39,39,,,,,,Other,Not Separately Reimbursable,32.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,32.18,82.5,,25.744,percent of total billed charges,Pays at 82.5% of total Billed charges,28.47,73,,22.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.3,70,,21.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,19.19,,5.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.5,50,,15.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,32.18,
VERY LONG CHAIN FATTY ACIDS,14030034,CDM,301,RC,83695,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
LIPOPROTEIN (A),14030035,CDM,302,RC,83013,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
Test of breath for a stomach bacterium,14030036,CDM,302,RC,85014,HCPCS,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,279.72,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,279.72,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,279.72,
HCT,14030049,CDM,305,RC,85018,HCPCS,Outpatient,,,44,44,,,,,,Other,Not Separately Reimbursable,10.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,10.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,32.12,73,,25.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.8,70,,24.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,19.19,,6.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22,50,,17.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,32.12,
Blood test to measure levels of hemoglobin,14030050,CDM,305,RC,86361,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,10.55,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,10.55,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,35.04,
CD4-T CELLS,14030069,CDM,300,RC,86215,HCPCS,Outpatient,,,6.25,6.25,,,,,,Other,Not Separately Reimbursable,5.16,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5.16,82.5,,4.128,percent of total billed charges,Pays at 82.5% of total Billed charges,4.56,73,,3.648,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.38,70,,3.504,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.2,19.19,,0.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.13,50,,2.504,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.2,5.16,
ANTI-DNase B (STREPTOCCOCAL) ANTIBODIES,14030070,CDM,302,RC,86225,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
ANTI-DSDNA,14030071,CDM,302,RC,85018,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,47.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.85,82.5,,38.28,percent of total billed charges,Pays at 82.5% of total Billed charges,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,47.85,
Blood test to measure levels of hemoglobin,14030072,CDM,305,RC,82172,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,10.55,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,10.55,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,35.04,
APOLIPOPROTEIN,14030073,CDM,301,RC,86147,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
ANTIPHOSPHOLIPID SNYD PR,14030074,CDM,302,RC,86226,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
ANTI-SS-DNA,14030075,CDM,302,RC,86255,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
ANTINEUTROPHIL CYTOPLASM,14030076,CDM,302,RC,86235,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
ANTI-SSA/B ANTIBODY-SJOGRENS,14030077,CDM,302,RC,86256,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,80.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,80.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,80.17,
ANTI-ENDOMYSIAL AB,14030078,CDM,302,RC,83520,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,53.9,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,53.9,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,53.9,
ANTI-GLIADIN AB,14030079,CDM,301,RC,82784,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,57.9,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,57.9,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,57.9,
Test to determine levels of immunoglobulins in the blood,14030080,CDM,301,RC,86256,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,41.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,41.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,41.58,
ANTI-RETICULUM AB,14030081,CDM,302,RC,84588,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,53.9,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,53.9,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,53.9,
ANTI-DIURETIC HORMONE,14030082,CDM,301,RC,82784,HCPCS,Outpatient,,,116,116,,,,,,Other,Not Separately Reimbursable,95.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,95.7,82.5,,76.56,percent of total billed charges,Pays at 82.5% of total Billed charges,84.68,73,,67.744,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.2,70,,64.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.26,19.19,,17.808,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58,50,,46.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.26,95.7,
Test to determine levels of immunoglobulins in the blood,14030083,CDM,301,RC,83516,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,41.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,41.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,41.58,
Chemical test of the blood to measure presence or concentration of a substance in the blood,14030084,CDM,301,RC,86235,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,51.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,51.6,
SMITH ANTIBODY,14030087,CDM,302,RC,86256,HCPCS,Outpatient,,,18.25,18.25,,,,,,Other,Not Separately Reimbursable,80.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,80.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,13.32,73,,10.656,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.78,70,,10.224,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,19.19,,2.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.13,50,,7.304,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,80.17,
ANTI-SMOOTH MUSCLE,14030088,CDM,302,RC,86318,HCPCS,Outpatient,,,23.98,23.98,,,,,,Other,Not Separately Reimbursable,19.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,19.78,82.5,,15.824,percent of total billed charges,Pays at 82.5% of total Billed charges,17.51,73,,14.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.79,70,,13.432,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.6,19.19,,3.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.99,50,,9.592,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.6,19.78,
ANTIGLOMERULAR BASEMENT MEMBRANE AB,14030089,CDM,302,RC,83498,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,57.9,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,57.9,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,57.9,
HYDROXYPROGESTERONE,14030096,CDM,301,RC,83003,HCPCS,Outpatient,,,93,93,,,,,,Other,Not Separately Reimbursable,76.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,76.73,82.5,,61.384,percent of total billed charges,Pays at 82.5% of total Billed charges,67.89,73,,54.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.1,70,,52.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.85,19.19,,14.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.5,50,,37.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.85,76.73,
"GROWTH HORMONE, SERUM",14030097,CDM,301,RC,86235,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,74.53,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,74.53,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,74.53,
ANTI-Sm (SMITH),14030098,CDM,302,RC,86235,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,80.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,80.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,80.17,
ANTI-HISTONE,14030099,CDM,302,RC,83520,HCPCS,Outpatient,,,21.12,21.12,,,,,,Other,Not Separately Reimbursable,80.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,80.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,15.42,73,,12.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,70,,11.824,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.05,19.19,,3.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.56,50,,8.448,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.05,80.17,
ANTI-RIBOSOMAL ABS,14030101,CDM,302,RC,87169,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,57.9,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,57.9,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,57.9,
PARASITIC IDENTIFICATION,14030102,CDM,306,RC,86682,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
ECHINOCOCCUS IGG ABS,14030103,CDM,302,RC,85044,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
RETIC COUNT,14030106,CDM,305,RC,86256,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,19.22,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,19.22,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,36.5,
ANTI-MYOCARDIAL AUTOANTIBODIES,14030107,CDM,302,RC,86021,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,53.9,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,53.9,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,53.9,
ANTI-MYELOPEROXIDASE AUTOANTIBODIES,14030108,CDM,302,RC,87101,HCPCS,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,66.75,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,66.75,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,73,
A procedure used to determine if fungi are present in an area of the body,14030109,CDM,302,RC,86235,HCPCS,Outpatient,,,15.25,15.25,,,,,,Other,Not Separately Reimbursable,34.46,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,34.46,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,11.13,73,,8.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.68,70,,8.544,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.93,19.19,,2.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.63,50,,6.104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.93,34.46,
ANTI-RNP,14030110,CDM,302,RC,86235,HCPCS,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
ANTI-SCL-70,14030111,CDM,302,RC,82785,HCPCS,Outpatient,,,24.84,24.84,,,,,,Other,Not Separately Reimbursable,80.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,80.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,18.13,73,,14.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.39,70,,13.912,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.77,19.19,,3.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.42,50,,9.936,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.77,80.17,
RAST NORTHERN FLORIDA AREA 3,14030112,CDM,302,RC,87116,HCPCS,Outpatient,,,144.86,144.86,,,,,,Other,Not Separately Reimbursable,73.65,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,73.65,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,105.75,73,,84.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.4,70,,81.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.8,19.19,,22.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.43,50,,57.944,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.8,105.75,
SPUTUM AFB,14030113,CDM,302,RC,85049,HCPCS,Outpatient,,,41.25,41.25,,,,,,Other,Not Separately Reimbursable,48.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,48.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,30.11,73,,24.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.88,70,,23.104,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.92,19.19,,6.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.63,50,,16.504,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.92,48.32,
PLATELET CT,14030114,CDM,305,RC,85651,HCPCS,Outpatient,,,99,99,,,,,,Other,Not Separately Reimbursable,81.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,81.68,82.5,,65.344,percent of total billed charges,Pays at 82.5% of total Billed charges,72.27,73,,57.816,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.3,70,,55.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,19.19,,15.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.5,50,,39.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,81.68,
SED RATE,14030122,CDM,305,RC,84260,HCPCS,Outpatient,,,111,111,,,,,,Other,Not Separately Reimbursable,15.88,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,15.88,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,81.03,73,,64.824,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.7,70,,62.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.3,19.19,,17.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.5,50,,44.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.88,81.03,
SEROTONIN,14030123,CDM,301,RC,81256,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,66.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,66.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,61.32,73,,49.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.8,70,,47.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,19.19,,12.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,50,,33.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,66.02,
HEMOCHROMATOSIS GENOTYPE,14030131,CDM,301,RC,86038,HCPCS,Outpatient,,,34,34,,,,,,Other,Not Separately Reimbursable,28.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.05,82.5,,22.44,percent of total billed charges,Pays at 82.5% of total Billed charges,24.82,73,,19.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,70,,19.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,19.19,,5.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17,50,,13.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,28.05,
PERINUCLEAR ANTI-NEUTROPHIL CYTOPLASMIC,14030136,CDM,302,RC,86021,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,54.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,54.02,
P-ANCA LEUCOCYTE ANTIBODY ID,14030137,CDM,302,RC,85002,HCPCS,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,66.75,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,66.75,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,73,
BLEEDING TIME,14030148,CDM,305,RC,80320,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,20.13,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,20.13,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,46.72,
BLOOD ALCOHOL,14030150,CDM,301,RC,85730,HCPCS,Outpatient,,,270,270,,,,,,Other,Not Separately Reimbursable,222.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,222.75,82.5,,178.2,percent of total billed charges,Pays at 82.5% of total Billed charges,197.1,73,,157.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,189,70,,151.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.81,19.19,,41.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,135,50,,108,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.81,222.75,
Coagulation assessment blood test,14030155,CDM,305,RC,,,Outpatient,,,138,138,,,,,,Other,Not Separately Reimbursable,26.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,26.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,100.74,73,,80.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.6,70,,77.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.48,19.19,,21.184,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69,50,,55.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.48,100.74,
VET PTT,14030156,CDM,301,RC,88230,HCPCS,Outpatient,,,98,98,,,,,,Other,Not Separately Reimbursable,80.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,80.85,82.5,,64.68,percent of total billed charges,Pays at 82.5% of total Billed charges,71.54,73,,57.232,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.6,70,,54.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.81,19.19,,15.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,50,,39.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.81,80.85,
TISSUE CULT/ CHROM/ANA,14030166,CDM,310,RC,80150,HCPCS,Outpatient,,,399,399,,,,,,Other,Not Separately Reimbursable,520.85,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,520.85,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,291.27,73,,233.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,279.3,70,,223.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.57,19.19,,61.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,199.5,50,,159.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.57,520.85,
AMIKACIN PEAK,14030168,CDM,301,RC,80150,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,67.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,67.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,67.38,
AMIKACIN TROUGH,14030169,CDM,301,RC,82525,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,67.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,67.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,67.38,
COPPER SERUM,14030170,CDM,301,RC,85610,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
"Blood test, clotting time",14030171,CDM,305,RC,83002,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,17.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,17.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,54.02,
LUTEINIZING HORMONE,14030172,CDM,301,RC,85610,HCPCS,Outpatient,,,88.48,88.48,,,,,,Other,Not Separately Reimbursable,73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,73,82.5,,58.4,percent of total billed charges,Pays at 82.5% of total Billed charges,64.59,73,,51.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.94,70,,49.552,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.98,19.19,,13.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.24,50,,35.392,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.98,73,
"Blood test, clotting time",14030173,CDM,305,RC,82626,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,17.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,17.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,54.02,
DHEA SERUM (NOT SH),14030174,CDM,301,RC,82390,HCPCS,Outpatient,,,145,145,,,,,,Other,Not Separately Reimbursable,119.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,119.63,82.5,,95.704,percent of total billed charges,Pays at 82.5% of total Billed charges,105.85,73,,84.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.5,70,,81.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.83,19.19,,22.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.5,50,,58,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.83,119.63,
CERULOPLASMIN,14030175,CDM,301,RC,80150,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,48.04,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,48.04,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,48.04,
AMIKACIN,14030176,CDM,301,RC,82085,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,67.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,67.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,67.38,
ALDOLASE,14030177,CDM,301,RC,84482,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,43.41,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,43.41,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,43.41,
"T3, REVERSE",14030178,CDM,301,RC,82525,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,68.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,68.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,48.18,73,,38.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.2,70,,36.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,19.19,,10.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33,50,,26.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,68.45,
COPPER-24 HR URINE,14030179,CDM,301,RC,84481,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
FREE T-3 (TRI-IODOTHYRONINE),14030180,CDM,301,RC,82627,HCPCS,Outpatient,,,21.49,21.49,,,,,,Other,Not Separately Reimbursable,17.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,17.73,82.5,,14.184,percent of total billed charges,Pays at 82.5% of total Billed charges,15.69,73,,12.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.04,70,,12.032,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.12,19.19,,3.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,50,,8.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.12,17.73,
"DHEA-S, SERUM (AT SH)",14030181,CDM,301,RC,82525,HCPCS,Outpatient,,,20.68,20.68,,,,,,Other,Not Separately Reimbursable,17.06,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,17.06,82.5,,13.648,percent of total billed charges,Pays at 82.5% of total Billed charges,15.1,73,,12.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.48,70,,11.584,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.97,19.19,,3.176,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.34,50,,8.272,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.97,17.06,
COPPER URINE RANDOM,14030182,CDM,301,RC,83002,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
Test of hormone in the blood,14030183,CDM,301,RC,83001,HCPCS,Outpatient,,,152,152,,,,,,Other,Not Separately Reimbursable,82.81,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,82.81,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,110.96,73,,88.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,106.4,70,,85.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.17,19.19,,23.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76,50,,60.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.17,110.96,
FSH- MALE,14030184,CDM,301,RC,,,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
VET PROTIME,14030185,CDM,301,RC,86713,HCPCS,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
LEGIONELLA ABS,14030190,CDM,302,RC,87278,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,68.42,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,68.42,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,68.42,
LEGIONELLA ANTIGEN,14030192,CDM,306,RC,88184,HCPCS,Outpatient,,,117,117,,,,,,Other,Not Separately Reimbursable,96.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,96.53,82.5,,77.224,percent of total billed charges,Pays at 82.5% of total Billed charges,85.41,73,,68.328,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.9,70,,65.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.45,19.19,,17.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.5,50,,46.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.45,96.53,
CELL SURFACE MARKER FIRST,14030195,CDM,300,RC,88185,HCPCS,Outpatient,,,101,101,,,,,,Other,Not Separately Reimbursable,83.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,83.33,82.5,,66.664,percent of total billed charges,Pays at 82.5% of total Billed charges,73.73,73,,58.984,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.7,70,,56.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,19.19,,15.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.5,50,,40.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,83.33,
CELL MARKER EACH ADDITIONAL,14030196,CDM,300,RC,89190,HCPCS,Outpatient,,,101,101,,,,,,Other,Not Separately Reimbursable,83.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,83.33,82.5,,66.664,percent of total billed charges,Pays at 82.5% of total Billed charges,73.73,73,,58.984,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.7,70,,56.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,19.19,,15.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.5,50,,40.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,83.33,
EOSINOPHIL COUNT,14030197,CDM,300,RC,85610,HCPCS,Outpatient,,,36,36,,,,,,Other,Not Separately Reimbursable,21.23,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,21.23,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,26.28,73,,21.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.2,70,,20.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,19.19,,5.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18,50,,14.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,26.28,
"Blood test, clotting time",14030215,CDM,305,RC,80175,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,17.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,17.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,51.1,
LAMICTAL LEVEL,14030224,CDM,301,RC,82542,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
PREGABALIN LEVEL,14030225,CDM,301,RC,80173,HCPCS,Outpatient,,,171,171,,,,,,Other,Not Separately Reimbursable,75.88,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,75.88,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,124.83,73,,99.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,119.7,70,,95.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.81,19.19,,26.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85.5,50,,68.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.81,124.83,
HALOPERIDOL LEVEL,14030226,CDM,301,RC,86753,HCPCS,Outpatient,,,162,162,,,,,,Other,Not Separately Reimbursable,133.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,133.65,82.5,,106.92,percent of total billed charges,Pays at 82.5% of total Billed charges,118.26,73,,94.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,113.4,70,,90.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.09,19.19,,24.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81,50,,64.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.09,133.65,
AMEBIASIS ANTIBODIES,14030233,CDM,302,RC,86628,HCPCS,Outpatient,,,124,124,,,,,,Other,Not Separately Reimbursable,55.41,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,55.41,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,90.52,73,,72.416,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.8,70,,69.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,19.19,,19.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62,50,,49.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,90.52,
CANDIDA ANTIBODIES,14030234,CDM,302,RC,80299,HCPCS,Outpatient,,,290,290,,,,,,Other,Not Separately Reimbursable,35.25,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,35.25,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,211.7,73,,169.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203,70,,162.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.65,19.19,,44.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,145,50,,116,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.25,211.7,
AMIODARONE CORDARONE LEVE,14030235,CDM,301,RC,86671,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,61.2,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,61.2,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,108.77,
"FUNGAL ANTIBODIES, QUANTITATIVE",14030236,CDM,302,RC,82495,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
CHROMIUM BLOOD,14030275,CDM,301,RC,82495,HCPCS,Outpatient,,,86,86,,,,,,Other,Not Separately Reimbursable,90.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,90.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,62.78,73,,50.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.2,70,,48.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,19.19,,13.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43,50,,34.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,90.69,
CHROMIUM SERUM,14030280,CDM,301,RC,85025,HCPCS,Outpatient,,,86,86,,,,,,Other,Not Separately Reimbursable,90.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,90.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,62.78,73,,50.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.2,70,,48.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,19.19,,13.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43,50,,34.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,90.69,
"Complete blood cell count, with differential white blood cells, automated",14030310,CDM,305,RC,80048,HCPCS,Outpatient,,,135,135,,,,,,Other,Not Separately Reimbursable,34.78,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,34.78,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,98.55,73,,78.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.5,70,,75.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.91,19.19,,20.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.5,50,,54,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.91,98.55,
Basic metabolic panel,14030311,CDM,301,RC,80053,HCPCS,Outpatient,,,148,148,,,,,,Other,Not Separately Reimbursable,36.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,36.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,108.04,73,,86.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.6,70,,82.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.4,19.19,,22.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74,50,,59.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.4,108.04,
"Blood test, comprehensive group of blood chemicals",14030312,CDM,301,RC,83735,HCPCS,Outpatient,,,225,225,,,,,,Other,Not Separately Reimbursable,46.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,46.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,164.25,73,,131.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.5,70,,126,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,19.19,,34.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112.5,50,,90,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,164.25,
DAILY MAGNESIUM SERUM,14030314,CDM,301,RC,86225,HCPCS,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,29.96,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,29.96,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,73,
ANTI-STRIATIONAL ANTIBODIES,14030315,CDM,302,RC,85610,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,61.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,61.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,61.43,
"Blood test, clotting time",14030318,CDM,305,RC,86225,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,17.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,17.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,54.02,
MUSK ABS,14030320,CDM,302,RC,86225,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,61.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,61.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,61.43,
IBD PANEL,14030325,CDM,302,RC,86225,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,61.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,61.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,61.43,
ANTI-TRYROTROPIN RECEPTOR ABS,14030330,CDM,302,RC,83519,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,61.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,61.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,61.43,
VOLTAGE-GATED CALCIUM CHANNEL ANTIBODY,14030335,CDM,301,RC,86403,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,60.39,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,60.39,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,151.11,
STREP PNEUMOMIAE ANTIGEN DETECTION,14030340,CDM,302,RC,80307,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,45.55,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,45.55,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,45.55,
"DRUG SCREEN,SERUM(5PANEL)",14030550,CDM,301,RC,80101,HCPCS,Outpatient,,,156,156,,,,,,Other,Not Separately Reimbursable,128.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,128.7,82.5,,102.96,percent of total billed charges,Pays at 82.5% of total Billed charges,113.88,73,,91.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.2,70,,87.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.94,19.19,,23.952,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78,50,,62.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.94,128.7,
DRUG SC/COLLECTION,14030573,CDM,301,RC,,,Outpatient,,,16,16,,,,,,Other,Not Separately Reimbursable,13.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13.2,82.5,,10.56,percent of total billed charges,Pays at 82.5% of total Billed charges,11.68,73,,9.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.2,70,,8.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,19.19,,2.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8,50,,6.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,13.2,
LAB CORP BLOOD COLLECTION,14030583,CDM,301,RC,,,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
LAB CORP URINE COLLECTION,14030584,CDM,301,RC,84702,HCPCS,Outpatient,,,8,8,,,,,,Other,Not Separately Reimbursable,6.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6.6,82.5,,5.28,percent of total billed charges,Pays at 82.5% of total Billed charges,5.84,73,,4.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.6,70,,4.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,19.19,,1.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4,50,,3.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,6.6,
HCG (QUANTITATIVE),14030939,CDM,301,RC,80061,HCPCS,Outpatient,,,204,204,,,,,,Other,Not Separately Reimbursable,67.28,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,67.28,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,148.92,73,,119.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,142.8,70,,114.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.15,19.19,,31.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102,50,,81.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.15,148.92,
"Blood test, lipids (cholesterol and triglycerides)",14030951,CDM,302,RC,,,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,59.88,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,59.88,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,59.88,
WRNC/EMPLOYEE HEP B TITER,14031005,CDM,301,RC,86765,HCPCS,Outpatient,,,16,16,,,,,,Other,Not Separately Reimbursable,13.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13.2,82.5,,10.56,percent of total billed charges,Pays at 82.5% of total Billed charges,11.68,73,,9.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.2,70,,8.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,19.19,,2.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8,50,,6.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,13.2,
Blood test to determine if antibodies exist for measles,14031020,CDM,302,RC,86592,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,57.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,57.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,57.61,
Blood test to screen for syphilis,14031021,CDM,302,RC,86762,HCPCS,Outpatient,,,7.26,7.26,,,,,,Other,Not Separately Reimbursable,19.09,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,19.09,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,5.3,73,,4.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.08,70,,4.064,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.39,19.19,,1.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.63,50,,2.904,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.39,19.09,
Blood test to determine if antibodies exist for rubella,14031024,CDM,302,RC,86762,HCPCS,Outpatient,,,61,61,,,,,,Other,Not Separately Reimbursable,64.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,64.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,44.53,73,,35.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.7,70,,34.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,19.19,,9.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.5,50,,24.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,64.35,
RUBELLA TITER,14031025,CDM,302,RC,86652,HCPCS,Outpatient,,,61,61,,,,,,Other,Not Separately Reimbursable,50.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,50.33,82.5,,40.264,percent of total billed charges,Pays at 82.5% of total Billed charges,44.53,73,,35.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.7,70,,34.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,19.19,,9.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.5,50,,24.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,50.33,
ARBOVIRUS PANEL SERUM,14031027,CDM,302,RC,86317,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,58.97,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,58.97,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,62.05,
"WEST NILE VIRUS, SERUM",14031028,CDM,302,RC,86788,HCPCS,Outpatient,,,63,63,,,,,,Other,Not Separately Reimbursable,67.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,67.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,45.99,73,,36.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.1,70,,35.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,19.19,,9.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,50,,25.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,67.03,
"WEST NILE VIRUS, CSF",14031029,CDM,302,RC,80329,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
SALICYLATES LEVEL (ASPIRIN),14031030,CDM,301,RC,83036,HCPCS,Outpatient,,,225,225,,,,,,Other,Not Separately Reimbursable,124.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,124.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,164.25,73,,131.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.5,70,,126,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,19.19,,34.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112.5,50,,90,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,164.25,
Blood test to measure average blood glucose levels for past 2-3 months,14031031,CDM,301,RC,83036,HCPCS,Outpatient,,,112,112,,,,,,Other,Not Separately Reimbursable,43.41,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,43.41,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,81.76,73,,65.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.4,70,,62.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,19.19,,17.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,50,,44.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,81.76,
Blood test to measure average blood glucose levels for past 2-3 months,14031033,CDM,301,RC,80194,HCPCS,Outpatient,,,112,112,,,,,,Other,Not Separately Reimbursable,43.41,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,43.41,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,81.76,73,,65.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.4,70,,62.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,19.19,,17.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,50,,44.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,81.76,
QUINIDINE,14031045,CDM,301,RC,86430,HCPCS,Outpatient,,,62,62,,,,,,Other,Not Separately Reimbursable,65.27,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.27,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,45.26,73,,36.208,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.4,70,,34.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,19.19,,9.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31,50,,24.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,65.27,
RA TEST,14031054,CDM,302,RC,85041,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,25.39,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,25.39,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,55.48,
RBC (ERYTHROCYTE COUNT),14031055,CDM,305,RC,86430,HCPCS,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,13.39,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,13.39,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,13.39,
RF TEST QUANTITATIVE,14031056,CDM,306,RC,86431,HCPCS,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,78.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,78.38,82.5,,62.704,percent of total billed charges,Pays at 82.5% of total Billed charges,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,78.38,
RHEUMATOID FACTOR IgG IgM IgA,14031057,CDM,302,RC,87530,HCPCS,Outpatient,,,91.75,91.75,,,,,,Other,Not Separately Reimbursable,75.69,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,75.69,82.5,,60.552,percent of total billed charges,Pays at 82.5% of total Billed charges,66.98,73,,53.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.23,70,,51.384,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.61,19.19,,14.088,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.88,50,,36.704,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.61,75.69,
HERPES SIMPLEX PCR DNA CSF,14031059,CDM,306,RC,83718,HCPCS,Outpatient,,,127,127,,,,,,Other,Not Separately Reimbursable,104.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,104.78,82.5,,83.824,percent of total billed charges,Pays at 82.5% of total Billed charges,92.71,73,,74.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.9,70,,71.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.37,19.19,,19.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.5,50,,50.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.37,104.78,
Blood test to measure the level of lipoproteins in the blood,14031060,CDM,301,RC,87255,HCPCS,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,36.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,36.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,65.7,
HERPES SIMPLEX VIRUS CULTURE/TYPING,14031061,CDM,306,RC,86308,HCPCS,Outpatient,,,68,68,,,,,,Other,Not Separately Reimbursable,56.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.1,82.5,,44.88,percent of total billed charges,Pays at 82.5% of total Billed charges,49.64,73,,39.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.6,70,,38.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,19.19,,10.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34,50,,27.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,56.1,
MONO TEST,14031062,CDM,302,RC,87206,HCPCS,Outpatient,,,138,138,,,,,,Other,Not Separately Reimbursable,23.12,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,23.12,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,100.74,73,,80.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.6,70,,77.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.48,19.19,,21.184,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69,50,,55.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.12,100.74,
HERPES(VARICELLA ZOSTER)ANTIBO.,14031063,CDM,306,RC,87252,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,24,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,24,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,59.13,
HERPES ZOSTER CULTURE,14031064,CDM,306,RC,86694,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,116.55,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,116.55,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,64.97,73,,51.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.3,70,,49.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,19.19,,13.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.5,50,,35.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,116.55,
"HERPES SIMPLEX I/II, IGG",14031065,CDM,302,RC,86695,HCPCS,Outpatient,,,33.2,33.2,,,,,,Other,Not Separately Reimbursable,64.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,64.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,24.24,73,,19.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.24,70,,18.592,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.37,19.19,,5.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.6,50,,13.28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.37,64.35,
"HERPES TYPE I, IGG",14031066,CDM,302,RC,86696,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
"HERPES TYPE II, IGG",14031067,CDM,302,RC,80183,HCPCS,Outpatient,,,82,82,,,,,,Other,Not Separately Reimbursable,67.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,67.65,82.5,,54.12,percent of total billed charges,Pays at 82.5% of total Billed charges,59.86,73,,47.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.4,70,,45.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,19.19,,12.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41,50,,32.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,67.65,
OXCARBAZEPINE,14031069,CDM,301,RC,86780,HCPCS,Outpatient,,,19.81,19.81,,,,,,Other,Not Separately Reimbursable,16.34,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.34,82.5,,13.072,percent of total billed charges,Pays at 82.5% of total Billed charges,14.46,73,,11.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.87,70,,11.096,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.8,19.19,,3.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.91,50,,7.928,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.8,16.34,
FTA- ABS,14031070,CDM,302,RC,88161,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
TZANCK SMEAR,14031071,CDM,311,RC,86790,HCPCS,Outpatient,,,101,101,,,,,,Other,Not Separately Reimbursable,83.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,83.33,82.5,,66.664,percent of total billed charges,Pays at 82.5% of total Billed charges,73.73,73,,58.984,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.7,70,,56.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,19.19,,15.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.5,50,,40.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,83.33,
HHV-6 AB IGG,14031072,CDM,302,RC,83937,HCPCS,Outpatient,,,45.54,45.54,,,,,,Other,Not Separately Reimbursable,57.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,57.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,33.24,73,,26.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.88,70,,25.504,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.74,19.19,,6.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.77,50,,18.216,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.74,57.61,
OSTEOCALCIN,14031073,CDM,301,RC,86780,HCPCS,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,89.52,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,89.52,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,63.51,73,,50.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.9,70,,48.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,19.19,,13.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.5,50,,34.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,89.52,
Blood test to determine existence of certain bacterium that causes syphilis,14031074,CDM,302,RC,86256,HCPCS,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,59.19,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,59.19,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,73,
ANTIMITOCHONDRIAL AB,14031075,CDM,302,RC,86800,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
THYROGLOBULIN AB,14031076,CDM,302,RC,85301,HCPCS,Outpatient,,,67,67,,,,,,Other,Not Separately Reimbursable,71.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,71.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,48.91,73,,39.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,70,,37.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,19.19,,10.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.5,50,,26.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,71.1,
ANTITHROMBIN III,14031077,CDM,305,RC,85301,HCPCS,Outpatient,,,37,37,,,,,,Other,Not Separately Reimbursable,48.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,48.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,27.01,73,,21.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.9,70,,20.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,19.19,,5.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.5,50,,14.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,48.35,
ANTI FACTOR XA,14031078,CDM,305,RC,86800,HCPCS,Outpatient,,,37,37,,,,,,Other,Not Separately Reimbursable,48.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,48.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,27.01,73,,21.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.9,70,,20.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,19.19,,5.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.5,50,,14.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,48.35,
ANTI-THYROID ABS,14031079,CDM,302,RC,84466,HCPCS,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,71.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,71.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,13.14,73,,10.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,70,,10.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,19.19,,2.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9,50,,7.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,71.1,
TRANSFERRIN,14031087,CDM,301,RC,84466,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,57.11,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,57.11,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,57.11,
TRANSFERRIN SATURATION,14031088,CDM,301,RC,82009,HCPCS,Outpatient,,,96,96,,,,,,Other,Not Separately Reimbursable,57.11,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,57.11,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,70.08,73,,56.064,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.2,70,,53.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,19.19,,14.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48,50,,38.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,70.08,
ACETONE/KETONES SERUM,14031090,CDM,301,RC,84311,HCPCS,Outpatient,,,122,122,,,,,,Other,Not Separately Reimbursable,20.19,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,20.19,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,89.06,73,,71.248,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85.4,70,,68.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.41,19.19,,18.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61,50,,48.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.19,89.06,
BETA HYDROXYBUTYRIC ACID,14031091,CDM,301,RC,87260,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,31.28,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,31.28,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,59.13,
ADENOVIRUS,14031092,CDM,306,RC,86710,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
"PARAINFLUENZA 1,2,3",14031093,CDM,302,RC,87798,HCPCS,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,60.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,60.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,60.61,
NORWALK AG STOOL,14031094,CDM,310,RC,86695,HCPCS,Outpatient,,,892,892,,,,,,Other,Not Separately Reimbursable,129.78,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,129.78,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,651.16,73,,520.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,624.4,70,,499.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,171.17,19.19,,136.936,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,446,50,,356.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,129.78,651.16,
VIRAL RESPIRATORY PANEL,14031095,CDM,302,RC,88273,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,58.97,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,58.97,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,58.97,
CHROMOSOMAL HYBRIDIZATION,14031097,CDM,310,RC,87420,HCPCS,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,78.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,78.38,82.5,,62.704,percent of total billed charges,Pays at 82.5% of total Billed charges,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,78.38,
RSV BY EIA (SWAB),14031098,CDM,306,RC,88273,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
MOLECULAR PROBE,14031099,CDM,310,RC,88273,HCPCS,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,78.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,78.38,82.5,,62.704,percent of total billed charges,Pays at 82.5% of total Billed charges,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,78.38,
CYTOGENICS INTERPRETATION,14031100,CDM,310,RC,86880,HCPCS,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,78.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,78.38,82.5,,62.704,percent of total billed charges,Pays at 82.5% of total Billed charges,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,78.38,
COOMBS DIRECT,14031112,CDM,302,RC,86850,HCPCS,Outpatient,,,62,62,,,,,,Other,Not Separately Reimbursable,24,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,24,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,45.26,73,,36.208,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.4,70,,34.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,19.19,,9.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31,50,,24.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,45.26,
Blood test to screen for antibodies that could harm red blood cells,14031120,CDM,302,RC,82775,HCPCS,Outpatient,,,109,109,,,,,,Other,Not Separately Reimbursable,89.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,89.93,82.5,,71.944,percent of total billed charges,Pays at 82.5% of total Billed charges,79.57,73,,63.656,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.3,70,,61.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.92,19.19,,16.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.5,50,,43.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.92,89.93,
GALACTOSE 1 PHOSPHATE,14031122,CDM,301,RC,83525,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,73.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,73.43,82.5,,58.744,percent of total billed charges,Pays at 82.5% of total Billed charges,64.97,73,,51.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.3,70,,49.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,19.19,,13.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.5,50,,35.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,73.43,
INSULIN LEVEL,14031125,CDM,301,RC,84305,HCPCS,Outpatient,,,12.1,12.1,,,,,,Other,Not Separately Reimbursable,51.12,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.12,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,8.83,73,,7.064,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.47,70,,6.776,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.32,19.19,,1.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.05,50,,4.84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.32,51.12,
INSULIN-LIKE GROWTH FACTOR I,14031126,CDM,301,RC,86337,HCPCS,Outpatient,,,83,83,,,,,,Other,Not Separately Reimbursable,85.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,85.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,60.59,73,,48.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.1,70,,46.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.93,19.19,,12.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.5,50,,33.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.93,85.84,
INSULIN ANTIBODIES,14031127,CDM,300,RC,84206,HCPCS,Outpatient,,,73,73,,,,,,Other,Not Separately Reimbursable,95.73,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,95.73,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,53.29,73,,42.632,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.1,70,,40.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.01,19.19,,11.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.5,50,,29.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.01,95.73,
PROINSULIN SERUM,14031128,CDM,301,RC,83516,HCPCS,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,58.34,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,58.34,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,58.34,
Chemical test of the blood to measure presence or concentration of a substance in the blood,14031129,CDM,301,RC,86341,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,51.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,51.6,
IA-2 ANTIBODY,14031130,CDM,300,RC,83519,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,88.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,88.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,88.45,
INSULIN-LIKE GROWTH FACTOR II,14031135,CDM,301,RC,82677,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,60.39,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,60.39,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,151.11,
ESTRIOL,14031456,CDM,301,RC,86162,HCPCS,Outpatient,,,83,83,,,,,,Other,Not Separately Reimbursable,68.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,68.48,82.5,,54.784,percent of total billed charges,Pays at 82.5% of total Billed charges,60.59,73,,48.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.1,70,,46.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.93,19.19,,12.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.5,50,,33.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.93,68.48,
CH50-TOTAL COMPLEMENT,14032000,CDM,302,RC,86200,HCPCS,Outpatient,,,86,86,,,,,,Other,Not Separately Reimbursable,90.81,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,90.81,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,62.78,73,,50.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.2,70,,48.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,19.19,,13.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43,50,,34.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,90.81,
CYCLIC CITRULLINATED PEPTIDE (CCP) ABS,14032001,CDM,300,RC,83018,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
BARIUM,14032002,CDM,301,RC,83018,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
BERYLLIUM,14032003,CDM,302,RC,86160,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
C1 ESTERASE INHIBITOR LEVEL,14032004,CDM,302,RC,86161,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
C1 ACTIVITY,14032005,CDM,302,RC,86332,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
IMMUNE COMPLEX ASSAY,14032006,CDM,302,RC,83090,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,69.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,69.3,82.5,,55.44,percent of total billed charges,Pays at 82.5% of total Billed charges,61.32,73,,49.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.8,70,,47.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,19.19,,12.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,50,,33.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,69.3,
MEGALOBLASTIC ANEMIA PANEL,14032008,CDM,301,RC,86160,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
C3 ANTIGEN (COMPLEMENT),14032010,CDM,302,RC,86658,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
COXSACKIE ANTIBODY,14032011,CDM,300,RC,86160,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
C2,14032013,CDM,302,RC,81327,HCPCS,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
BCR/ABL,14032014,CDM,302,RC,86160,HCPCS,Outpatient,,,425,425,,,,,,Other,Not Separately Reimbursable,350.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,350.63,82.5,,280.504,percent of total billed charges,Pays at 82.5% of total Billed charges,310.25,73,,248.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,297.5,70,,238,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.56,19.19,,65.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,212.5,50,,170,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.56,350.63,
C4 ANTIGEN,14032020,CDM,302,RC,80051,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
"Blood test panel for electrolytes (sodium potassium, chloride, carbon dioxide)",14032029,CDM,301,RC,82672,HCPCS,Outpatient,,,97,97,,,,,,Other,Not Separately Reimbursable,30.52,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,30.52,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,70.81,73,,56.648,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.9,70,,54.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.61,19.19,,14.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.5,50,,38.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.61,70.81,
ESTROGEN,14032030,CDM,301,RC,89060,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
SYNOVIAL FLUID-CRYSTAL,14032031,CDM,300,RC,83872,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,47.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.85,82.5,,38.28,percent of total billed charges,Pays at 82.5% of total Billed charges,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,47.85,
MUCIN CLOT TEST-SYNOVIAL FLUID,14032032,CDM,301,RC,82672,HCPCS,Outpatient,,,68,68,,,,,,Other,Not Separately Reimbursable,56.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.1,82.5,,44.88,percent of total billed charges,Pays at 82.5% of total Billed charges,49.64,73,,39.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.6,70,,38.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,19.19,,10.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34,50,,27.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,56.1,
TOTAL ESTROGEN,14032034,CDM,301,RC,84295,HCPCS,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,23.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.93,82.5,,19.144,percent of total billed charges,Pays at 82.5% of total Billed charges,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,23.93,
SODIUM,14032037,CDM,301,RC,86376,HCPCS,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,21.48,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,21.48,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,22.63,73,,18.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.7,70,,17.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,19.19,,4.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.5,50,,12.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,22.63,
ANTI-LIVER KIDNEY MICROSOME ANTIBODY,14032039,CDM,302,RC,,,Outpatient,,,61,61,,,,,,Other,Not Separately Reimbursable,50.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,50.33,82.5,,40.264,percent of total billed charges,Pays at 82.5% of total Billed charges,44.53,73,,35.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.7,70,,34.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,19.19,,9.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.5,50,,24.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,50.33,
VET UA,14032040,CDM,300,RC,84132,HCPCS,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
POTASSIUM,14032045,CDM,301,RC,83519,HCPCS,Outpatient,,,67,67,,,,,,Other,Not Separately Reimbursable,20.54,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,20.54,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,48.91,73,,39.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,70,,37.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,19.19,,10.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.5,50,,26.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,48.91,
VOLTAGE GATED CALCIUM CHANNEL IGG ABS,14032050,CDM,301,RC,82435,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,170.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,170.78,82.5,,136.624,percent of total billed charges,Pays at 82.5% of total Billed charges,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,170.78,
CHLORIDE BLOOD,14032052,CDM,301,RC,82530,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,20.54,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,20.54,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,38.69,73,,30.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.1,70,,29.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,19.19,,8.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.5,50,,21.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,38.69,
CORTISOL URINE FREE,14032053,CDM,301,RC,84403,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
TESTOSTERONE-TOTAL (CHILD/FEMALE),14032055,CDM,301,RC,82383,HCPCS,Outpatient,,,117,117,,,,,,Other,Not Separately Reimbursable,96.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,96.53,82.5,,77.224,percent of total billed charges,Pays at 82.5% of total Billed charges,85.41,73,,68.328,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.9,70,,65.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.45,19.19,,17.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.5,50,,46.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.45,96.53,
EPINEPHRINE PLASMA,14032056,CDM,301,RC,82374,HCPCS,Outpatient,,,86,86,,,,,,Other,Not Separately Reimbursable,70.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.95,82.5,,56.76,percent of total billed charges,Pays at 82.5% of total Billed charges,62.78,73,,50.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.2,70,,48.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,19.19,,13.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43,50,,34.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,70.95,
BICARBONATE URINE,14032057,CDM,301,RC,83150,HCPCS,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,47.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.03,82.5,,37.624,percent of total billed charges,Pays at 82.5% of total Billed charges,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,47.03,
HOMOVANILLIC ACID(HVA) 24HR URINE,14032058,CDM,301,RC,83835,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
METANEPHRINES-PLASMA,14032059,CDM,301,RC,82374,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,47.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.85,82.5,,38.28,percent of total billed charges,Pays at 82.5% of total Billed charges,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,47.85,
CARBON DIOXIDE (CO2) TOTAL,14032060,CDM,301,RC,82384,HCPCS,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,21.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,21.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,41.61,
"CATECHOL,FRAC URINARY-FREE",14032061,CDM,301,RC,82383,HCPCS,Outpatient,,,79,79,,,,,,Other,Not Separately Reimbursable,65.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,65.18,82.5,,52.144,percent of total billed charges,Pays at 82.5% of total Billed charges,57.67,73,,46.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.3,70,,44.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,19.19,,12.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.5,50,,31.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,65.18,
CATECHOLAMINES-PLASMA,14032062,CDM,301,RC,84585,HCPCS,Outpatient,,,79,79,,,,,,Other,Not Separately Reimbursable,65.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,65.18,82.5,,52.144,percent of total billed charges,Pays at 82.5% of total Billed charges,57.67,73,,46.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.3,70,,44.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,19.19,,12.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.5,50,,31.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,65.18,
CATECHOLAMINES-VMA,14032063,CDM,301,RC,83835,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,43.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,43.73,82.5,,34.984,percent of total billed charges,Pays at 82.5% of total Billed charges,38.69,73,,30.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.1,70,,29.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,19.19,,8.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.5,50,,21.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,43.73,
METANEPHRINES 24 HR URINE,14032064,CDM,301,RC,83835,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,47.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.85,82.5,,38.28,percent of total billed charges,Pays at 82.5% of total Billed charges,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,47.85,
"METANEPHRINES, RANDOM URINE",14032065,CDM,301,RC,83918,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
METHYLMALONIC ACID,14032066,CDM,301,RC,80053,HCPCS,Outpatient,,,22,22,,,,,,Other,Not Separately Reimbursable,18.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.15,82.5,,14.52,percent of total billed charges,Pays at 82.5% of total Billed charges,16.06,73,,12.848,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.4,70,,12.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,19.19,,3.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11,50,,8.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,18.15,
"Blood test, comprehensive group of blood chemicals",14032068,CDM,301,RC,,,Outpatient,,,225,225,,,,,,Other,Not Separately Reimbursable,46.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,46.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,164.25,73,,131.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.5,70,,126,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,19.19,,34.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112.5,50,,90,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,164.25,
VET CHEM PANEL,14032069,CDM,301,RC,87521,HCPCS,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
"HEPATITIS C RNA/PCR,QUAL",14032070,CDM,306,RC,,,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
VET MISC CHEMISTRY,14032071,CDM,300,RC,82308,HCPCS,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
CALCITONIN,14032072,CDM,301,RC,82330,HCPCS,Outpatient,,,316,316,,,,,,Other,Not Separately Reimbursable,260.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,260.7,82.5,,208.56,percent of total billed charges,Pays at 82.5% of total Billed charges,230.68,73,,184.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,221.2,70,,176.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.64,19.19,,48.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,158,50,,126.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.64,260.7,
CALCIUM IONIZED,14032073,CDM,301,RC,84403,HCPCS,Outpatient,,,91,91,,,,,,Other,Not Separately Reimbursable,75.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,75.08,82.5,,60.064,percent of total billed charges,Pays at 82.5% of total Billed charges,66.43,73,,53.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.7,70,,50.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.46,19.19,,13.968,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,50,,36.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.46,75.08,
TESTOSTERONE-TOTAL,14032074,CDM,301,RC,86304,HCPCS,Outpatient,,,17.8,17.8,,,,,,Other,Not Separately Reimbursable,14.69,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.69,82.5,,11.752,percent of total billed charges,Pays at 82.5% of total Billed charges,12.99,73,,10.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.46,70,,9.968,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.42,19.19,,2.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.9,50,,7.12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.42,14.69,
CA 125,14032075,CDM,302,RC,86612,HCPCS,Outpatient,,,28.38,28.38,,,,,,Other,Not Separately Reimbursable,23.41,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.41,82.5,,18.728,percent of total billed charges,Pays at 82.5% of total Billed charges,20.72,73,,16.576,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.87,70,,15.896,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.45,19.19,,4.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.19,50,,11.352,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.45,23.41,
BLASTOMYCES ANTIBODIES SC,14032076,CDM,302,RC,82360,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
CALCULI ANALYSIS,14032077,CDM,301,RC,82310,HCPCS,Outpatient,,,82,82,,,,,,Other,Not Separately Reimbursable,67.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,67.65,82.5,,54.12,percent of total billed charges,Pays at 82.5% of total Billed charges,59.86,73,,47.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.4,70,,45.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,19.19,,12.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41,50,,32.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,67.65,
CALCIUM,14032078,CDM,301,RC,82941,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,23.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,23.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,43.8,
GASTRIN,14032079,CDM,301,RC,86804,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
HEPATITIS C ANTIBODY(RIBA),14032081,CDM,302,RC,87902,HCPCS,Outpatient,,,91,91,,,,,,Other,Not Separately Reimbursable,75.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,75.08,82.5,,60.064,percent of total billed charges,Pays at 82.5% of total Billed charges,66.43,73,,53.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.7,70,,50.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.46,19.19,,13.968,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,50,,36.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.46,75.08,
HEPATITIS C VIRUS GENOTYPING,14032082,CDM,301,RC,84146,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
PROLACTIN,14032083,CDM,301,RC,87522,HCPCS,Outpatient,,,36.52,36.52,,,,,,Other,Not Separately Reimbursable,30.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,30.13,82.5,,24.104,percent of total billed charges,Pays at 82.5% of total Billed charges,26.66,73,,21.328,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.56,70,,20.448,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.01,19.19,,5.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.26,50,,14.608,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.01,30.13,
"HEPATITIS C RNA/PCR,QUAN",14032084,CDM,306,RC,80101,HCPCS,Outpatient,,,90.86,90.86,,,,,,Other,Not Separately Reimbursable,74.96,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.96,82.5,,59.968,percent of total billed charges,Pays at 82.5% of total Billed charges,66.33,73,,53.064,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.6,70,,50.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.44,19.19,,13.952,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.43,50,,36.344,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.44,74.96,
"NICOTINE(COTININE)SCREEN,URINE",14032085,CDM,301,RC,84520,HCPCS,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,93.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,93.23,82.5,,74.584,percent of total billed charges,Pays at 82.5% of total Billed charges,82.49,73,,65.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.1,70,,63.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,19.19,,17.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.5,50,,45.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,93.23,
BUN,14032086,CDM,301,RC,86698,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,17.64,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,17.64,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,51.83,
HISTOPLASMA ANTIBODIES SC,14032087,CDM,302,RC,86635,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,43.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,43.73,82.5,,34.984,percent of total billed charges,Pays at 82.5% of total Billed charges,38.69,73,,30.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.1,70,,29.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,19.19,,8.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.5,50,,21.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,43.73,
COCCIDIODES ANTIBODIES SC,14032088,CDM,302,RC,86606,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
ASPERGILLUS ANTIBODY,14032089,CDM,302,RC,84585,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
VMA 24 HOUR URINE,14032091,CDM,301,RC,84585,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,43.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,43.73,82.5,,34.984,percent of total billed charges,Pays at 82.5% of total Billed charges,38.69,73,,30.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.1,70,,29.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,19.19,,8.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.5,50,,21.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,43.73,
VMA RANDOM URINE,14032092,CDM,301,RC,82382,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,43.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,43.73,82.5,,34.984,percent of total billed charges,Pays at 82.5% of total Billed charges,38.69,73,,30.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.1,70,,29.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,19.19,,8.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.5,50,,21.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,43.73,
CATECHOLAMINES TOTAL URINE 24 HR,14032093,CDM,301,RC,82947,HCPCS,Outpatient,,,73,73,,,,,,Other,Not Separately Reimbursable,60.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,60.23,82.5,,48.184,percent of total billed charges,Pays at 82.5% of total Billed charges,53.29,73,,42.632,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.1,70,,40.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.01,19.19,,11.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.5,50,,29.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.01,60.23,
Quantitative measure of glucose build up in the blood over time,14032094,CDM,301,RC,85420,HCPCS,Outpatient,,,36,36,,,,,,Other,Not Separately Reimbursable,17.55,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,17.55,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,26.28,73,,21.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.2,70,,20.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,19.19,,5.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18,50,,14.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,26.28,
PLASMINOGEN ACTIVITY,14032095,CDM,301,RC,85362,HCPCS,Outpatient,,,36,36,,,,,,Other,Not Separately Reimbursable,29.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,29.7,82.5,,23.76,percent of total billed charges,Pays at 82.5% of total Billed charges,26.28,73,,21.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.2,70,,20.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,19.19,,5.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18,50,,14.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,29.7,
FDP,14032096,CDM,300,RC,85670,HCPCS,Outpatient,,,96,96,,,,,,Other,Not Separately Reimbursable,79.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,79.2,82.5,,63.36,percent of total billed charges,Pays at 82.5% of total Billed charges,70.08,73,,56.064,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.2,70,,53.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,19.19,,14.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48,50,,38.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,79.2,
THROMBIN TIME,14032097,CDM,300,RC,81240,HCPCS,Outpatient,,,67,67,,,,,,Other,Not Separately Reimbursable,55.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,55.28,82.5,,44.224,percent of total billed charges,Pays at 82.5% of total Billed charges,48.91,73,,39.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,70,,37.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,19.19,,10.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.5,50,,26.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,55.28,
FASTING PROTHROMBIN MUTATION (FA2G),14032098,CDM,300,RC,87536,HCPCS,Outpatient,,,43,43,,,,,,Other,Not Separately Reimbursable,35.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,35.48,82.5,,28.384,percent of total billed charges,Pays at 82.5% of total Billed charges,31.39,73,,25.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.1,70,,24.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,19.19,,6.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.5,50,,17.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,35.48,
"HIV BY PCR,QUANTITATIVE",14032099,CDM,306,RC,86703,HCPCS,Outpatient,,,65.12,65.12,,,,,,Other,Not Separately Reimbursable,53.72,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.72,82.5,,42.976,percent of total billed charges,Pays at 82.5% of total Billed charges,47.54,73,,38.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.58,70,,36.464,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,19.19,,10,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.56,50,,26.048,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,53.72,
Blood test to diagnose HIV,14032100,CDM,302,RC,86689,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,59.91,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,59.91,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,59.91,
HTLV OR HIV WESTERN BLOT,14032101,CDM,302,RC,83874,HCPCS,Outpatient,,,82,82,,,,,,Other,Not Separately Reimbursable,67.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,67.65,82.5,,54.12,percent of total billed charges,Pays at 82.5% of total Billed charges,59.86,73,,47.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.4,70,,45.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,19.19,,12.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41,50,,32.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,67.65,
MYOGLOBIN QUALITATIVE,14032103,CDM,301,RC,87207,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
MALARIAL SMEAR,14032104,CDM,306,RC,83874,HCPCS,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,31.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,31.35,82.5,,25.08,percent of total billed charges,Pays at 82.5% of total Billed charges,27.74,73,,22.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.6,70,,21.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,19.19,,5.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,50,,15.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,31.35,
MYOGLOBIN URINE,14032105,CDM,301,RC,86905,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
RBC ANTIGENS,14032106,CDM,300,RC,87904,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
HIV-PHENOTYPE ADDITIONAL DRUG,14032107,CDM,300,RC,87903,HCPCS,Outpatient,,,77,77,,,,,,Other,Not Separately Reimbursable,63.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,63.53,82.5,,50.824,percent of total billed charges,Pays at 82.5% of total Billed charges,56.21,73,,44.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.9,70,,43.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,19.19,,11.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,50,,30.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,63.53,
HIV-PHENOTYPE,14032108,CDM,300,RC,83874,HCPCS,Outpatient,,,756,756,,,,,,Other,Not Separately Reimbursable,623.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,623.7,82.5,,498.96,percent of total billed charges,Pays at 82.5% of total Billed charges,551.88,73,,441.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,529.2,70,,423.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,145.08,19.19,,116.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,378,50,,302.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,145.08,623.7,
MYOGLOBIN QUANTITATIVE,14032109,CDM,301,RC,82951,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
Test to predict likelihood of gestational diabetes,14032112,CDM,301,RC,83520,HCPCS,Outpatient,,,102,102,,,,,,Other,Not Separately Reimbursable,50.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,50.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,74.46,73,,59.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.4,70,,57.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,19.19,,15.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51,50,,40.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,74.46,
RNA POLY I/II/III ABS,14032113,CDM,301,RC,86235,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
ANTISCLERODERMA,14032114,CDM,302,RC,86235,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,62.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,62.7,82.5,,50.16,percent of total billed charges,Pays at 82.5% of total Billed charges,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,62.7,
ANTI-JO-1,14032115,CDM,302,RC,86340,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,62.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,62.7,82.5,,50.16,percent of total billed charges,Pays at 82.5% of total Billed charges,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,62.7,
GASTRIC INTRINSIC FACTOR BLOCKING ABS,14032116,CDM,300,RC,82383,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
NOREPINEPHRINE PLASMA,14032117,CDM,301,RC,81270,HCPCS,Outpatient,,,182,182,,,,,,Other,Not Separately Reimbursable,150.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,150.15,82.5,,120.12,percent of total billed charges,Pays at 82.5% of total Billed charges,132.86,73,,106.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,127.4,70,,101.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.93,19.19,,27.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,50,,72.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.93,150.15,
JAKA 2 (V617F) WHOLE BLD OR NAHEP,14032118,CDM,302,RC,82172,HCPCS,Outpatient,,,400,400,,,,,,Other,Not Separately Reimbursable,330,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,330,82.5,,264,percent of total billed charges,Pays at 82.5% of total Billed charges,292,73,,233.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280,70,,224,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.76,19.19,,61.408,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,200,50,,160,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.76,330,
HEP C FIBROSURE,14032119,CDM,302,RC,,,Outpatient,,,263.75,263.75,,,,,,Other,Not Separately Reimbursable,61.68,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,61.68,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,192.54,73,,154.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,184.63,70,,147.704,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.61,19.19,,40.488,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,131.88,50,,105.504,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.61,192.54,
VET PROGESTERONE SERUM,14032120,CDM,301,RC,81596,HCPCS,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
FIBROSURE,14032121,CDM,302,RC,82172,HCPCS,Outpatient,,,165,165,,,,,,Other,Not Separately Reimbursable,136.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,136.13,82.5,,108.904,percent of total billed charges,Pays at 82.5% of total Billed charges,120.45,73,,96.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.5,70,,92.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.66,19.19,,25.328,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.5,50,,66,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.66,136.13,
FIBROSURE NASH,14032122,CDM,302,RC,87015,HCPCS,Outpatient,,,275,275,,,,,,Other,Not Separately Reimbursable,61.68,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,61.68,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,200.75,73,,160.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,192.5,70,,154,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.77,19.19,,42.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.5,50,,110,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.77,200.75,
MICROSPORIDA STOOL,14032123,CDM,302,RC,82672,HCPCS,Outpatient,,,67,67,,,,,,Other,Not Separately Reimbursable,29.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,29.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,48.91,73,,39.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,70,,37.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,19.19,,10.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.5,50,,26.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,48.91,
"ESTROGEN, TOTAL",14032124,CDM,302,RC,80050,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,96.96,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,96.96,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,96.96,
General health panel,14032125,CDM,301,RC,86677,HCPCS,Outpatient,,,155,155,,,,,,Other,Not Separately Reimbursable,157.91,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,157.91,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,113.15,73,,90.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108.5,70,,86.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.74,19.19,,23.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.5,50,,62,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.74,157.91,
Blood test to if peptic ulcers are caused by a certain bacterium,14032126,CDM,302,RC,U0003,HCPCS,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,64.89,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,64.89,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,64.89,
COVID19 [MERS-COV] SEND OUT,14032127,CDM,301,RC,86769,HCPCS,Outpatient,,,205,205,,,,,,Other,Not Separately Reimbursable,169.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,169.13,82.5,,135.304,percent of total billed charges,Pays at 82.5% of total Billed charges,149.65,73,,119.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.5,70,,114.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,19.19,,31.472,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.5,50,,82,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,169.13,
COVID19 TOTAL ANTIBODY [SARS-COV-2],14032128,CDM,301,RC,82952,HCPCS,Outpatient,,,142,142,,,,,,Other,Not Separately Reimbursable,117.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,117.15,82.5,,93.72,percent of total billed charges,Pays at 82.5% of total Billed charges,103.66,73,,82.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.4,70,,79.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,19.19,,21.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,50,,56.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,117.15,
GLUCOSE TOL EA ADD HR,14032130,CDM,301,RC,82950,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,15.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,15.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,61.32,73,,49.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.8,70,,47.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,19.19,,12.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,50,,33.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.03,61.32,
Test of glucose level in the blood,14032131,CDM,301,RC,87426,HCPCS,Outpatient,,,82,82,,,,,,Other,Not Separately Reimbursable,17.92,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,17.92,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,59.86,73,,47.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.4,70,,45.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,19.19,,12.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41,50,,32.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,59.86,
COVID (MERS) RAPID Ag,14032132,CDM,301,RC,87636,HCPCS,Outpatient,,,213,213,,,,,,Other,Not Separately Reimbursable,175.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,175.73,82.5,,140.584,percent of total billed charges,Pays at 82.5% of total Billed charges,155.49,73,,124.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.1,70,,119.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.87,19.19,,32.696,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,106.5,50,,85.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.87,175.73,
COVID/FLU (RAPID),14032133,CDM,301,RC,86769,HCPCS,Outpatient,,,213,213,,,,,,Other,Not Separately Reimbursable,175.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,175.73,82.5,,140.584,percent of total billed charges,Pays at 82.5% of total Billed charges,155.49,73,,124.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.1,70,,119.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.87,19.19,,32.696,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,106.5,50,,85.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.87,175.73,
COVID19 ANTIBODY [SARS-CoV-2],14032135,CDM,300,RC,84181,HCPCS,Outpatient,,,142,142,,,,,,Other,Not Separately Reimbursable,117.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,117.15,82.5,,93.72,percent of total billed charges,Pays at 82.5% of total Billed charges,103.66,73,,82.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.4,70,,79.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,19.19,,21.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,50,,56.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,117.15,
WB IMMUNO PROBE,14032150,CDM,301,RC,84100,HCPCS,Outpatient,,,72,72,,,,,,Other,Not Separately Reimbursable,59.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,59.4,82.5,,47.52,percent of total billed charges,Pays at 82.5% of total Billed charges,52.56,73,,42.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.4,70,,40.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,19.19,,11.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36,50,,28.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,59.4,
PHOSPHORUS,14032151,CDM,301,RC,81241,HCPCS,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,21.2,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,21.2,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,63.51,73,,50.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.9,70,,48.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,19.19,,13.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.5,50,,34.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,63.51,
FACTOR 5 LEIDEN DNA TEST,14032152,CDM,301,RC,84479,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
T-3 UPTAKE,14032153,CDM,301,RC,85245,HCPCS,Outpatient,,,86,86,,,,,,Other,Not Separately Reimbursable,28.95,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,28.95,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,62.78,73,,50.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.2,70,,48.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,19.19,,13.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43,50,,34.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,62.78,
FACTOR 8,14032154,CDM,305,RC,85250,HCPCS,Outpatient,,,146,146,,,,,,Other,Not Separately Reimbursable,120.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,120.45,82.5,,96.36,percent of total billed charges,Pays at 82.5% of total Billed charges,106.58,73,,85.264,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.2,70,,81.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.02,19.19,,22.416,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73,50,,58.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.02,120.45,
FACTOR 9,14032155,CDM,305,RC,81240,HCPCS,Outpatient,,,94,94,,,,,,Other,Not Separately Reimbursable,77.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,77.55,82.5,,62.04,percent of total billed charges,Pays at 82.5% of total Billed charges,68.62,73,,54.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.8,70,,52.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.04,19.19,,14.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47,50,,37.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.04,77.55,
FACTOR 2 GENE MUTATION/DNA TEST,14032156,CDM,301,RC,85220,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
FACTOR 5,14032157,CDM,305,RC,85260,HCPCS,Outpatient,,,94,94,,,,,,Other,Not Separately Reimbursable,77.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,77.55,82.5,,62.04,percent of total billed charges,Pays at 82.5% of total Billed charges,68.62,73,,54.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.8,70,,52.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.04,19.19,,14.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47,50,,37.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.04,77.55,
FACTOR X,14032158,CDM,305,RC,85230,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,62.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,62.7,82.5,,50.16,percent of total billed charges,Pays at 82.5% of total Billed charges,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,62.7,
FACTOR VII,14032159,CDM,305,RC,84126,HCPCS,Outpatient,,,82,82,,,,,,Other,Not Separately Reimbursable,67.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,67.65,82.5,,54.12,percent of total billed charges,Pays at 82.5% of total Billed charges,59.86,73,,47.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.4,70,,45.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,19.19,,12.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41,50,,32.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,67.65,
"PORPHYRINS, STOOL QUANTITATIVE",14032160,CDM,301,RC,84120,HCPCS,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,71.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,71.78,82.5,,57.424,percent of total billed charges,Pays at 82.5% of total Billed charges,63.51,73,,50.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.9,70,,48.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,19.19,,13.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.5,50,,34.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,71.78,
PORPHYRINS QUANT URINE,14032161,CDM,301,RC,84436,HCPCS,Outpatient,,,62,62,,,,,,Other,Not Separately Reimbursable,51.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,51.15,82.5,,40.92,percent of total billed charges,Pays at 82.5% of total Billed charges,45.26,73,,36.208,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.4,70,,34.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,19.19,,9.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31,50,,24.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,51.15,
Blood test to measure a type of thyroid hormone,14032163,CDM,301,RC,80156,HCPCS,Outpatient,,,114,114,,,,,,Other,Not Separately Reimbursable,30.74,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,30.74,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,83.22,73,,66.576,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.8,70,,63.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.88,19.19,,17.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57,50,,45.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.88,83.22,
TEGRETOL TOTAL(CARBAMAZEPINE),14032165,CDM,301,RC,84484,HCPCS,Outpatient,,,162,162,,,,,,Other,Not Separately Reimbursable,65.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,118.26,73,,94.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,113.4,70,,90.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.09,19.19,,24.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81,50,,64.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.09,118.26,
Blood test to measure a certain protein in the blood to determine heart muscle damage,14032166,CDM,301,RC,84155,HCPCS,Outpatient,,,142,142,,,,,,Other,Not Separately Reimbursable,117.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,117.15,82.5,,93.72,percent of total billed charges,Pays at 82.5% of total Billed charges,103.66,73,,82.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.4,70,,79.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,19.19,,21.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,50,,56.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,117.15,
PROTEIN TOTAL,14032169,CDM,301,RC,82977,HCPCS,Outpatient,,,43,43,,,,,,Other,Not Separately Reimbursable,16.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,16.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,31.39,73,,25.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.1,70,,24.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,19.19,,6.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.5,50,,17.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,31.39,
GGT-SERUM,14032170,CDM,301,RC,86147,HCPCS,Outpatient,,,109,109,,,,,,Other,Not Separately Reimbursable,32.16,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,32.16,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,79.57,73,,63.656,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.3,70,,61.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.92,19.19,,16.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.5,50,,43.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.92,79.57,
CARDIOLIPIN ANTIBODIES,14032171,CDM,302,RC,85613,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
LUPUS SCREEN,14032172,CDM,305,RC,84480,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
Blood test to evaluate thyroid function,14032173,CDM,301,RC,86235,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,63.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,63.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,63.38,
LUPUS PROFILE A SLE,14032174,CDM,302,RC,86235,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,62.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,62.7,82.5,,50.16,percent of total billed charges,Pays at 82.5% of total Billed charges,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,62.7,
LUPUS PROFILE B SLE,14032175,CDM,302,RC,84270,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,62.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,62.7,82.5,,50.16,percent of total billed charges,Pays at 82.5% of total Billed charges,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,62.7,
SEX HORMONE BINDING GLOBULIN (SHBG),14032176,CDM,301,RC,82040,HCPCS,Outpatient,,,34,34,,,,,,Other,Not Separately Reimbursable,28.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.05,82.5,,22.44,percent of total billed charges,Pays at 82.5% of total Billed charges,24.82,73,,19.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,70,,19.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,19.19,,5.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17,50,,13.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,28.05,
ALBUMIN SERUM,14032177,CDM,301,RC,80299,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,17.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,17.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,40.15,
DESYREL(TRAZODONE),14032182,CDM,301,RC,84443,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
"Blood test, thyroid stimulating hormone (TSH)",14032183,CDM,301,RC,84443,HCPCS,Outpatient,,,175,175,,,,,,Other,Not Separately Reimbursable,75.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,75.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,127.75,73,,102.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.5,70,,98,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.58,19.19,,26.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,50,,70,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.58,127.75,
"Blood test, thyroid stimulating hormone (TSH)",14032185,CDM,301,RC,84432,HCPCS,Outpatient,,,168,168,,,,,,Other,Not Separately Reimbursable,75.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,75.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,122.64,73,,98.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.6,70,,94.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.24,19.19,,25.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,50,,67.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.24,122.64,
THYROXINE BINDING GLOBULIN,14032186,CDM,302,RC,84442,HCPCS,Outpatient,,,68,68,,,,,,Other,Not Separately Reimbursable,71.82,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,71.82,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,49.64,73,,39.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.6,70,,38.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,19.19,,10.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34,50,,27.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,71.82,
THYROXINE BINDING GLOBULIN,14032187,CDM,302,RC,84432,HCPCS,Outpatient,,,24.62,24.62,,,,,,Other,Not Separately Reimbursable,65.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,17.97,73,,14.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.23,70,,13.784,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.72,19.19,,3.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.31,50,,9.848,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.72,65.58,
THYROGLOBULIN QUANTITATIVE,14032188,CDM,302,RC,84443,HCPCS,Outpatient,,,169,169,,,,,,Other,Not Separately Reimbursable,71.82,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,71.82,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,123.37,73,,98.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,118.3,70,,94.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.43,19.19,,25.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.5,50,,67.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.43,123.37,
"Blood test, thyroid stimulating hormone (TSH)",14032193,CDM,301,RC,80061,HCPCS,Outpatient,,,168,168,,,,,,Other,Not Separately Reimbursable,75.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,75.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,122.64,73,,98.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.6,70,,94.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.24,19.19,,25.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,50,,67.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.24,122.64,
"Blood test, lipids (cholesterol and triglycerides)",14032194,CDM,301,RC,86376,HCPCS,Outpatient,,,195,195,,,,,,Other,Not Separately Reimbursable,59.88,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,59.88,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,142.35,73,,113.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,136.5,70,,109.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.42,19.19,,29.936,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.5,50,,78,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.42,142.35,
ANTI-THYROID MICROSOMAL ABS,14032195,CDM,302,RC,84445,HCPCS,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,65.05,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.05,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,65.05,
THY STIMULATING IMMUNOGLOBULIN,14032196,CDM,301,RC,84479,HCPCS,Outpatient,,,115,115,,,,,,Other,Not Separately Reimbursable,94.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,94.88,82.5,,75.904,percent of total billed charges,Pays at 82.5% of total Billed charges,83.95,73,,67.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.5,70,,64.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.07,19.19,,17.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.5,50,,46,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.07,94.88,
THYROID HORMONE UPTAKE,14032197,CDM,301,RC,84436,HCPCS,Outpatient,,,86,86,,,,,,Other,Not Separately Reimbursable,70.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.95,82.5,,56.76,percent of total billed charges,Pays at 82.5% of total Billed charges,62.78,73,,50.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.2,70,,48.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,19.19,,13.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43,50,,34.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,70.95,
Blood test to measure a type of thyroid hormone,14032198,CDM,301,RC,85613,HCPCS,Outpatient,,,114,114,,,,,,Other,Not Separately Reimbursable,30.74,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,30.74,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,83.22,73,,66.576,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.8,70,,63.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.88,19.19,,17.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57,50,,45.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.88,83.22,
ANTICOAGULANT PROFILE (LC# 500070),14032200,CDM,305,RC,83550,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
Blood test that measures the amount of iron carried in the blood,14032201,CDM,301,RC,83540,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,39.06,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,39.06,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,62.05,
Blood test to measure the amount of iron that is in transit in the body,14032202,CDM,301,RC,82175,HCPCS,Outpatient,,,96,96,,,,,,Other,Not Separately Reimbursable,28.98,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,28.98,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,70.08,73,,56.064,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.2,70,,53.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,19.19,,14.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48,50,,38.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,70.08,
ARSENIC 24 HR URINE,14032253,CDM,301,RC,83655,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
LEAD 24 HR URINE,14032256,CDM,301,RC,83825,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
MERCURY 24 HR URINE,14032259,CDM,301,RC,83002,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
FSH/LH/PROLACT (AMENORRHEA PROF),14032335,CDM,301,RC,82985,HCPCS,Outpatient,,,152,152,,,,,,Other,Not Separately Reimbursable,125.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,125.4,82.5,,100.32,percent of total billed charges,Pays at 82.5% of total Billed charges,110.96,73,,88.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,106.4,70,,85.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.17,19.19,,23.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76,50,,60.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.17,125.4,
FRUCTOSAMINE,14032336,CDM,301,RC,82760,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
GALACTOSE URINE QUANTITATIVE,14032338,CDM,301,RC,87340,HCPCS,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,38.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,38.78,82.5,,31.024,percent of total billed charges,Pays at 82.5% of total Billed charges,34.31,73,,27.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.9,70,,26.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,19.19,,7.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.5,50,,18.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,38.78,
HEPATITIS B SURF ANTIGEN,14032400,CDM,306,RC,83010,HCPCS,Outpatient,,,63,63,,,,,,Other,Not Separately Reimbursable,51.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,51.98,82.5,,41.584,percent of total billed charges,Pays at 82.5% of total Billed charges,45.99,73,,36.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.1,70,,35.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,19.19,,9.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,50,,25.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,51.98,
HAPTOGLOBIN,14032409,CDM,301,RC,86709,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,43.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,43.73,82.5,,34.984,percent of total billed charges,Pays at 82.5% of total Billed charges,38.69,73,,30.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.1,70,,29.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,19.19,,8.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.5,50,,21.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,43.73,
HEPATITIS A ANTIBODY,14032410,CDM,302,RC,83015,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
ARSENIC HEAVY METAL,14032411,CDM,301,RC,83825,HCPCS,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
"MERCURY, URINE",14032413,CDM,301,RC,83519,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
TRYPSIN,14032414,CDM,301,RC,87799,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,170.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,170.78,82.5,,136.624,percent of total billed charges,Pays at 82.5% of total Billed charges,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,170.78,
EP BARR VIRUS QUANT BY PCR,14032415,CDM,301,RC,G0103,HCPCS,Outpatient,,,229,229,,,,,,Other,Not Separately Reimbursable,188.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,188.93,82.5,,151.144,percent of total billed charges,Pays at 82.5% of total Billed charges,167.17,73,,133.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,160.3,70,,128.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.95,19.19,,35.16,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,114.5,50,,91.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.95,188.93,
Prostate cancer screening; prostate specific antigen test (psa),14032416,CDM,301,RC,82108,HCPCS,Outpatient,,,201,201,,,,,,Other,Not Separately Reimbursable,165.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,165.83,82.5,,132.664,percent of total billed charges,Pays at 82.5% of total Billed charges,146.73,73,,117.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140.7,70,,112.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.57,19.19,,30.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.5,50,,80.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.57,165.83,
ALUMINUM,14032418,CDM,301,RC,82735,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
FLUORIDE,14032419,CDM,301,RC,86704,HCPCS,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,31.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,31.35,82.5,,25.08,percent of total billed charges,Pays at 82.5% of total Billed charges,27.74,73,,22.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.6,70,,21.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,19.19,,5.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,50,,15.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,31.35,
HEPATITIS B CORE ANTIBODY,14032420,CDM,302,RC,83018,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
SILVER LEVEL,14032421,CDM,301,RC,87590,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
NEISERRIA ONLY DIRECT PROBE,14032425,CDM,306,RC,87490,HCPCS,Outpatient,,,25.41,25.41,,,,,,Other,Not Separately Reimbursable,20.96,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,20.96,82.5,,16.768,percent of total billed charges,Pays at 82.5% of total Billed charges,18.55,73,,14.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.79,70,,14.232,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.88,19.19,,3.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.71,50,,10.168,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.88,20.96,
CHLAMYDIA ONLY DIRECT PROBE,14032426,CDM,306,RC,87490,HCPCS,Outpatient,,,25.41,25.41,,,,,,Other,Not Separately Reimbursable,20.96,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,20.96,82.5,,16.768,percent of total billed charges,Pays at 82.5% of total Billed charges,18.55,73,,14.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.79,70,,14.232,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.88,19.19,,3.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.71,50,,10.168,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.88,20.96,
CHLAM P IGG AB,14032427,CDM,306,RC,87210,HCPCS,Outpatient,,,24,24,,,,,,Other,Not Separately Reimbursable,19.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,19.8,82.5,,15.84,percent of total billed charges,Pays at 82.5% of total Billed charges,17.52,73,,14.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.8,70,,13.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.61,19.19,,3.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12,50,,9.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.61,19.8,
A lab test to screen for evidence of vaginal infection,14032428,CDM,306,RC,86706,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,19.09,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,19.09,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,59.13,
HEPATITIS B SURF AB TITER,14032429,CDM,302,RC,86658,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
POLIO TITER,14032430,CDM,302,RC,86707,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
HEPATITIS BE ANTIBODY,14032432,CDM,302,RC,87350,HCPCS,Outpatient,,,49,49,,,,,,Other,Not Separately Reimbursable,40.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,40.43,82.5,,32.344,percent of total billed charges,Pays at 82.5% of total Billed charges,35.77,73,,28.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.3,70,,27.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,19.19,,7.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,50,,19.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,40.43,
HEPATITIS BE ANTIGEN,14032433,CDM,306,RC,86803,HCPCS,Outpatient,,,49,49,,,,,,Other,Not Separately Reimbursable,40.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,40.43,82.5,,32.344,percent of total billed charges,Pays at 82.5% of total Billed charges,35.77,73,,28.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.3,70,,27.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,19.19,,7.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,50,,19.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,40.43,
HEPATITIS C ANTIBODY,14032437,CDM,302,RC,87340,HCPCS,Outpatient,,,15.71,15.71,,,,,,Other,Not Separately Reimbursable,12.96,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.96,82.5,,10.368,percent of total billed charges,Pays at 82.5% of total Billed charges,11.47,73,,9.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11,70,,8.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.01,19.19,,2.408,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.86,50,,6.288,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.01,12.96,
HEPATITIS PANEL A&B,14032439,CDM,306,RC,80074,HCPCS,Outpatient,,,63,63,,,,,,Other,Not Separately Reimbursable,51.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,51.98,82.5,,41.584,percent of total billed charges,Pays at 82.5% of total Billed charges,45.99,73,,36.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.1,70,,35.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,19.19,,9.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,50,,25.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,51.98,
HEPATITIS ACUTE PANEL,14032440,CDM,301,RC,86707,HCPCS,Outpatient,,,62.04,62.04,,,,,,Other,Not Separately Reimbursable,51.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,51.18,82.5,,40.944,percent of total billed charges,Pays at 82.5% of total Billed charges,45.29,73,,36.232,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.43,70,,34.744,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.91,19.19,,9.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.02,50,,24.816,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.91,51.18,
HEPATITIS PROFILE III,14032441,CDM,302,RC,87340,HCPCS,Outpatient,,,49,49,,,,,,Other,Not Separately Reimbursable,40.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,40.43,82.5,,32.344,percent of total billed charges,Pays at 82.5% of total Billed charges,35.77,73,,28.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.3,70,,27.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,19.19,,7.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,50,,19.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,40.43,
HEPATITIS PANEL B&C,14032442,CDM,306,RC,86000,HCPCS,Outpatient,,,63,63,,,,,,Other,Not Separately Reimbursable,51.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,51.98,82.5,,41.584,percent of total billed charges,Pays at 82.5% of total Billed charges,45.99,73,,36.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.1,70,,35.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,19.19,,9.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,50,,25.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,51.98,
TULAREMIA AGGLUTININS,14032457,CDM,302,RC,82105,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
AFP TUMOR MARKER,14032459,CDM,301,RC,82105,HCPCS,Outpatient,,,15.62,15.62,,,,,,Other,Not Separately Reimbursable,12.89,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.89,82.5,,10.312,percent of total billed charges,Pays at 82.5% of total Billed charges,11.4,73,,9.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.93,70,,8.744,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,19.19,,2.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.81,50,,6.248,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,12.89,
AFP MATERNAL TRIPLE TEST,14032461,CDM,301,RC,82105,HCPCS,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
AFP QUAD TEST,14032462,CDM,301,RC,82105,HCPCS,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
AFP MSAFP (ONTD ONLY),14032463,CDM,301,RC,84484,HCPCS,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
Blood test to measure a certain protein in the blood to determine heart muscle damage,14032467,CDM,301,RC,82088,HCPCS,Outpatient,,,142,142,,,,,,Other,Not Separately Reimbursable,117.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,117.15,82.5,,93.72,percent of total billed charges,Pays at 82.5% of total Billed charges,103.66,73,,82.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.4,70,,79.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,19.19,,21.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,50,,56.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,117.15,
ALDOSTERONE SERUM,14032501,CDM,301,RC,82088,HCPCS,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
"ALDOSTERONE,24 HR URINE",14032502,CDM,301,RC,86256,HCPCS,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
ADRENAL AUTOANITBODIES,14032507,CDM,302,RC,82127,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
GLUTAMIC ACID DECARBOXYLASE AUTOABS,14032508,CDM,301,RC,82300,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
CADMIUM WHOLE BLOOD,14032510,CDM,301,RC,82565,HCPCS,Outpatient,,,102,102,,,,,,Other,Not Separately Reimbursable,84.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,84.15,82.5,,67.32,percent of total billed charges,Pays at 82.5% of total Billed charges,74.46,73,,59.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.4,70,,57.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,19.19,,15.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51,50,,40.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,84.15,
CREATININE,14032532,CDM,301,RC,82540,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,22.9,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,22.9,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,51.1,
CREATINE,14032533,CDM,301,RC,86140,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
C REACTIVE PROTEIN,14032534,CDM,302,RC,82595,HCPCS,Outpatient,,,29.35,29.35,,,,,,Other,Not Separately Reimbursable,24.21,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.21,82.5,,19.368,percent of total billed charges,Pays at 82.5% of total Billed charges,21.43,73,,17.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.55,70,,16.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.63,19.19,,4.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.68,50,,11.744,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.63,24.21,
"CRYOGLOBULIN, QUALITATIVE",14032535,CDM,301,RC,86141,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
CRP HIGH SENSITIVITY,14032536,CDM,302,RC,86141,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
C REACTIVE PROTEIN HS,14032537,CDM,302,RC,87206,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
"REDUCING SUBSTANCES, STOOL",14032538,CDM,306,RC,83986,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
STOOL PH,14032539,CDM,301,RC,84550,HCPCS,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,16,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,16,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,30.66,
URIC ACID,14032540,CDM,301,RC,84105,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,20.19,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,20.19,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,51.83,
PHOSPHORUS URINE 24 HR,14032541,CDM,301,RC,83945,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
OXALATE-URINE 24 HR,14032542,CDM,301,RC,82507,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
CITRATE-24 HR URINE,14032543,CDM,301,RC,87206,HCPCS,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,78.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,78.38,82.5,,62.704,percent of total billed charges,Pays at 82.5% of total Billed charges,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,78.38,
CRYPTOSPORIDIUM STOOL,14032544,CDM,306,RC,87327,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
CRYPTOCOCCUS ANTIGEN,14032545,CDM,306,RC,83735,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,73.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,73.43,82.5,,58.744,percent of total billed charges,Pays at 82.5% of total Billed charges,64.97,73,,51.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.3,70,,49.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,19.19,,13.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.5,50,,35.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,73.43,
MAGNESIUM-URINE 24HR,14032546,CDM,301,RC,83986,HCPCS,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
URINE COMPONENT SINGLE,14032547,CDM,301,RC,87327,HCPCS,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,16,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,16,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,30.66,
CRYPTOCOCCUS ANTIGEN WITH TITER,14032548,CDM,306,RC,84105,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,73.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,73.43,82.5,,58.744,percent of total billed charges,Pays at 82.5% of total Billed charges,64.97,73,,51.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.3,70,,49.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,19.19,,13.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.5,50,,35.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,73.43,
PHOSPHORUS URINE RANDOM,14032549,CDM,301,RC,83690,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
LIPASE,14032557,CDM,301,RC,80176,HCPCS,Outpatient,,,162,162,,,,,,Other,Not Separately Reimbursable,30.78,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,30.78,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,118.26,73,,94.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,113.4,70,,90.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.09,19.19,,24.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81,50,,64.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.78,118.26,
LIDOCAINE,14032558,CDM,301,RC,82375,HCPCS,Outpatient,,,49,49,,,,,,Other,Not Separately Reimbursable,40.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,40.43,82.5,,32.344,percent of total billed charges,Pays at 82.5% of total Billed charges,35.77,73,,28.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.3,70,,27.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,19.19,,7.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,50,,19.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,40.43,
CARBON MONOXIDE BLOOD (CO),14032559,CDM,301,RC,83916,HCPCS,Outpatient,,,124,124,,,,,,Other,Not Separately Reimbursable,102.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,102.3,82.5,,81.84,percent of total billed charges,Pays at 82.5% of total Billed charges,90.52,73,,72.416,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.8,70,,69.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,19.19,,19.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62,50,,49.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,102.3,
"OLIGOCLONAL BAND PROFILE, CSF",14032560,CDM,301,RC,80299,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
CORDARONE LEVEL,14032561,CDM,301,RC,83519,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
BN PEP [B-TYPE NATRIURETIC PEPTIDE],14032562,CDM,301,RC,83090,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,60.39,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,60.39,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,151.11,
HOMOCYSTINE,14032563,CDM,301,RC,,,Outpatient,,,29.35,29.35,,,,,,Other,Not Separately Reimbursable,24.21,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.21,82.5,,19.368,percent of total billed charges,Pays at 82.5% of total Billed charges,21.43,73,,17.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.55,70,,16.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.63,19.19,,4.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.68,50,,11.744,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.63,24.21,
TORCH IGG PROFILE,14032569,CDM,301,RC,82785,HCPCS,Outpatient,,,167,167,,,,,,Other,Not Separately Reimbursable,137.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,137.78,82.5,,110.224,percent of total billed charges,Pays at 82.5% of total Billed charges,121.91,73,,97.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.9,70,,93.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,19.19,,25.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.5,50,,66.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,137.78,
IMMUNOGLOBULIN IGE,14032570,CDM,301,RC,86003,HCPCS,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
IGE RAST,14032571,CDM,302,RC,86003,HCPCS,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,15.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,15.68,82.5,,12.544,percent of total billed charges,Pays at 82.5% of total Billed charges,13.87,73,,11.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.3,70,,10.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,19.19,,2.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.5,50,,7.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,15.68,
LATEX SPECIFIC IGE,14032572,CDM,301,RC,82247,HCPCS,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,15.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,15.68,82.5,,12.544,percent of total billed charges,Pays at 82.5% of total Billed charges,13.87,73,,11.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.3,70,,10.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,19.19,,2.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.5,50,,7.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,15.68,
BILIRUBIN TOTAL,14032573,CDM,301,RC,86777,HCPCS,Outpatient,,,68,68,,,,,,Other,Not Separately Reimbursable,21.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,21.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,49.64,73,,39.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.6,70,,38.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,19.19,,10.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34,50,,27.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,49.64,
"TOXOPLASM TITER,IGG",14032574,CDM,302,RC,86778,HCPCS,Outpatient,,,61,61,,,,,,Other,Not Separately Reimbursable,50.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,50.33,82.5,,40.264,percent of total billed charges,Pays at 82.5% of total Billed charges,44.53,73,,35.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.7,70,,34.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,19.19,,9.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.5,50,,24.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,50.33,
"TOXOPLASM TITER,IGM",14032575,CDM,302,RC,83520,HCPCS,Outpatient,,,61,61,,,,,,Other,Not Separately Reimbursable,50.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,50.33,82.5,,40.264,percent of total billed charges,Pays at 82.5% of total Billed charges,44.53,73,,35.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.7,70,,34.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,19.19,,9.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.5,50,,24.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,50.33,
ANTI-TISSUE TRANSGLUTAMASE IGA ABS,14032576,CDM,302,RC,,,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
TORCH IGM PROFILE,14032577,CDM,301,RC,83520,HCPCS,Outpatient,,,167,167,,,,,,Other,Not Separately Reimbursable,137.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,137.78,82.5,,110.224,percent of total billed charges,Pays at 82.5% of total Billed charges,121.91,73,,97.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.9,70,,93.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,19.19,,25.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.5,50,,66.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,137.78,
"ANTI-TISSUE TRANSGLUTAMASE IGG,IGA ABS",14032578,CDM,302,RC,86341,HCPCS,Outpatient,,,54.5,54.5,,,,,,Other,Not Separately Reimbursable,44.96,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.96,82.5,,35.968,percent of total billed charges,Pays at 82.5% of total Billed charges,39.79,73,,31.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.15,70,,30.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.46,19.19,,8.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,50,,21.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.46,44.96,
ISLET CELL AUTOANTIBODIES,14032579,CDM,301,RC,82787,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
IMMUNOGLOBULIN IGG SUBCLASS(1-4),14032580,CDM,301,RC,82784,HCPCS,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
"IMMUNOGLOBULINS IGG,IGA,IGM",14032581,CDM,301,RC,86335,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,26.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,26.4,82.5,,21.12,percent of total billed charges,Pays at 82.5% of total Billed charges,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,26.4,
IFE RANDOM URINE,14032582,CDM,302,RC,82784,HCPCS,Outpatient,,,77,77,,,,,,Other,Not Separately Reimbursable,63.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,63.53,82.5,,50.824,percent of total billed charges,Pays at 82.5% of total Billed charges,56.21,73,,44.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.9,70,,43.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,19.19,,11.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,50,,30.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,63.53,
IMMUNOGLOBULIN IGG,14032583,CDM,301,RC,82784,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,26.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,26.4,82.5,,21.12,percent of total billed charges,Pays at 82.5% of total Billed charges,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,26.4,
IMMUNOGLOBULIN IGM,14032584,CDM,301,RC,87210,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,26.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,26.4,82.5,,21.12,percent of total billed charges,Pays at 82.5% of total Billed charges,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,26.4,
INDIA INK PREPARATION,14032585,CDM,306,RC,86325,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
IFE 24HR URINE,14032586,CDM,301,RC,82784,HCPCS,Outpatient,,,77,77,,,,,,Other,Not Separately Reimbursable,63.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,63.53,82.5,,50.824,percent of total billed charges,Pays at 82.5% of total Billed charges,56.21,73,,44.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.9,70,,43.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,19.19,,11.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,50,,30.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,63.53,
IMMUNOGLOBULIN IGA,14032587,CDM,301,RC,86320,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,26.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,26.4,82.5,,21.12,percent of total billed charges,Pays at 82.5% of total Billed charges,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,26.4,
IFE SERUM,14032588,CDM,301,RC,82232,HCPCS,Outpatient,,,77,77,,,,,,Other,Not Separately Reimbursable,63.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,63.53,82.5,,50.824,percent of total billed charges,Pays at 82.5% of total Billed charges,56.21,73,,44.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.9,70,,43.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,19.19,,11.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,50,,30.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,63.53,
BETA 2 PROTEIN,14032589,CDM,301,RC,83883,HCPCS,Outpatient,,,68,68,,,,,,Other,Not Separately Reimbursable,56.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.1,82.5,,44.88,percent of total billed charges,Pays at 82.5% of total Billed charges,49.64,73,,39.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.6,70,,38.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,19.19,,10.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34,50,,27.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,56.1,
SERUM FREE LIGHT CHAINS QUANT(KAP/LAMB),14032591,CDM,301,RC,83519,HCPCS,Outpatient,,,77,77,,,,,,Other,Not Separately Reimbursable,63.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,63.53,82.5,,50.824,percent of total billed charges,Pays at 82.5% of total Billed charges,56.21,73,,44.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.9,70,,43.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,19.19,,11.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,50,,30.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,63.53,
IGF BINDING PROTEIN,14032592,CDM,301,RC,83520,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,170.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,170.78,82.5,,136.624,percent of total billed charges,Pays at 82.5% of total Billed charges,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,170.78,
ANTI-TISSUE TRANSGLUTAMASE IGG ABS,14032593,CDM,302,RC,83519,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
DAILY BNP [B-TYPE NATRIURETIC PEPTIDE],14032599,CDM,301,RC,83519,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,60.39,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,60.39,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,151.11,
BNP [NT PRO],14032600,CDM,301,RC,87517,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,60.39,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,60.39,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,151.11,
"HEPATITIS B,DNA BY PCR-QUANTITATIVE",14032605,CDM,306,RC,83036,HCPCS,Outpatient,,,179,179,,,,,,Other,Not Separately Reimbursable,147.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,147.68,82.5,,118.144,percent of total billed charges,Pays at 82.5% of total Billed charges,130.67,73,,104.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125.3,70,,100.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.35,19.19,,27.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.5,50,,71.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.35,147.68,
Blood test to measure average blood glucose levels for past 2-3 months,14032606,CDM,301,RC,83020,HCPCS,Outpatient,,,112,112,,,,,,Other,Not Separately Reimbursable,43.41,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,43.41,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,81.76,73,,65.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.4,70,,62.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,19.19,,17.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,50,,44.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,81.76,
HGB FRACTIONATION PROFILE,14032607,CDM,301,RC,87516,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,73.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,73.43,82.5,,58.744,percent of total billed charges,Pays at 82.5% of total Billed charges,64.97,73,,51.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.3,70,,49.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,19.19,,13.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.5,50,,35.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,73.43,
"HEPATITIS B,DNA PCR-QUALITATIVE",14032608,CDM,306,RC,86790,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,165,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,165,82.5,,132,percent of total billed charges,Pays at 82.5% of total Billed charges,146,73,,116.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,70,,112,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,19.19,,30.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100,50,,80,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,165,
"HTLV I/HTLV II,QUALITATIVE",14032609,CDM,302,RC,86360,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
Lymphocyte Helper/Suppressor Panel,14032610,CDM,300,RC,87912,HCPCS,Outpatient,,,202.5,202.5,,,,,,Other,Not Separately Reimbursable,30.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,30.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,147.83,73,,118.264,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,141.75,70,,113.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.86,19.19,,31.088,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.25,50,,81,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.43,147.83,
HEP B VIRUS GENOTYPE,14032611,CDM,301,RC,84165,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
PROTEIN ELECT SERUM,14032615,CDM,301,RC,84166,HCPCS,Outpatient,,,11.44,11.44,,,,,,Other,Not Separately Reimbursable,9.44,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.44,82.5,,7.552,percent of total billed charges,Pays at 82.5% of total Billed charges,8.35,73,,6.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.01,70,,6.408,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.2,19.19,,1.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.72,50,,4.576,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.2,9.44,
PROTEIN ELECT 24 HR URINE,14032616,CDM,301,RC,83700,HCPCS,Outpatient,,,127,127,,,,,,Other,Not Separately Reimbursable,104.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,104.78,82.5,,83.824,percent of total billed charges,Pays at 82.5% of total Billed charges,92.71,73,,74.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.9,70,,71.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.37,19.19,,19.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.5,50,,50.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.37,104.78,
LIPOPROTEIN PHENOTYPING,14032623,CDM,301,RC,84450,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
SGOT AST,14032631,CDM,301,RC,84460,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,23.09,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,23.09,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,54.75,
Blood test to evaluate liver function,14032649,CDM,301,RC,83615,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,23.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,23.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,54.75,
LDH,14032656,CDM,301,RC,83721,HCPCS,Outpatient,,,93,93,,,,,,Other,Not Separately Reimbursable,27,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,27,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,67.89,73,,54.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.1,70,,52.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.85,19.19,,14.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.5,50,,37.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.85,67.89,
LDL BY CALCULATION,14032657,CDM,301,RC,83721,HCPCS,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,42.65,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,42.65,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,58.4,
LDL BY DIRECT MEASURE,14032658,CDM,301,RC,82550,HCPCS,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
CPK,14032672,CDM,301,RC,82465,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,29.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,29.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,67.16,73,,53.728,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.4,70,,51.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,19.19,,14.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46,50,,36.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,67.16,
"CHOLESTEROL, TOTAL",14032680,CDM,301,RC,84478,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,14.77,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,14.77,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,54.75,
TRIGLYCERIDES,14032698,CDM,301,RC,87661,HCPCS,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,25.7,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,25.7,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.7,102.2,
Blood test for an STD,14032699,CDM,301,RC,84140,HCPCS,Outpatient,,,107.75,107.75,,,,,,Other,Not Separately Reimbursable,88.89,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,88.89,82.5,,71.112,percent of total billed charges,Pays at 82.5% of total Billed charges,78.66,73,,62.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75.43,70,,60.344,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.68,19.19,,16.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.88,50,,43.104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.68,88.89,
PREGNENOLONE,14032700,CDM,301,RC,83520,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
ANTI-SOLUBLE LIVER ANTIGEN,14032701,CDM,301,RC,83519,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
ALPHA SUBUNIT PIT. GLYCOPROTEIN HORMONE,14032702,CDM,301,RC,82103,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,170.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,170.78,82.5,,136.624,percent of total billed charges,Pays at 82.5% of total Billed charges,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,170.78,
ALPHA-1 ANTI TRYPSIN LABCORP,14032703,CDM,301,RC,84402,HCPCS,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,47.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.03,82.5,,37.624,percent of total billed charges,Pays at 82.5% of total Billed charges,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,47.03,
"TEST,FREE/TOTAL WITH SBGH",14032705,CDM,301,RC,84075,HCPCS,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,71.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,71.78,82.5,,57.424,percent of total billed charges,Pays at 82.5% of total Billed charges,63.51,73,,50.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.9,70,,48.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,19.19,,13.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.5,50,,34.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,71.78,
ALKALINE PHOSPHATASE,14032706,CDM,301,RC,84402,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,23.12,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,23.12,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,47.45,
"TEST,FREE/TOTAL NO SBGH",14032707,CDM,301,RC,84402,HCPCS,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,71.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,71.78,82.5,,57.424,percent of total billed charges,Pays at 82.5% of total Billed charges,63.51,73,,50.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.9,70,,48.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,19.19,,13.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.5,50,,34.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,71.78,
"TEST,FREE ONLY",14032708,CDM,301,RC,85306,HCPCS,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,71.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,71.78,82.5,,57.424,percent of total billed charges,Pays at 82.5% of total Billed charges,63.51,73,,50.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.9,70,,48.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,19.19,,13.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.5,50,,34.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,71.78,
PROTEIN S ACTIVITY,14032709,CDM,305,RC,84066,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
PROSTATIC ACID PHOSPHATASE,14032710,CDM,301,RC,84311,HCPCS,Outpatient,,,41,41,,,,,,Other,Not Separately Reimbursable,33.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33.83,82.5,,27.064,percent of total billed charges,Pays at 82.5% of total Billed charges,29.93,73,,23.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.7,70,,22.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,19.19,,6.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.5,50,,16.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,33.83,
ADENOSINE DEAMINASE,14032711,CDM,301,RC,80299,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
PROLIXIN,14032712,CDM,301,RC,84402,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
"TESTOSTERONE, BIOAVAILABLE",14032713,CDM,301,RC,82024,HCPCS,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,71.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,71.78,82.5,,57.424,percent of total billed charges,Pays at 82.5% of total Billed charges,63.51,73,,50.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.9,70,,48.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,19.19,,13.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.5,50,,34.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,71.78,
ACTH-ADRENAL CORTICOTROPIN,14032715,CDM,301,RC,84075,HCPCS,Outpatient,,,132,132,,,,,,Other,Not Separately Reimbursable,108.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,108.9,82.5,,87.12,percent of total billed charges,Pays at 82.5% of total Billed charges,96.36,73,,77.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.4,70,,73.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.33,19.19,,20.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66,50,,52.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.33,108.9,
ALKALINE PHOSP W/ISO'S,14032716,CDM,301,RC,84075,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
ALK PHOS BONE SPECIFIC,14032717,CDM,301,RC,82705,HCPCS,Outpatient,,,56.7,56.7,,,,,,Other,Not Separately Reimbursable,46.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.78,82.5,,37.424,percent of total billed charges,Pays at 82.5% of total Billed charges,41.39,73,,33.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.69,70,,31.752,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.88,19.19,,8.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.35,50,,22.68,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.88,46.78,
FECAL FAT QUALITATIVE,14032718,CDM,301,RC,80299,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,28.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.88,82.5,,23.104,percent of total billed charges,Pays at 82.5% of total Billed charges,25.55,73,,20.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,70,,19.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,19.19,,5.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,50,,14,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,28.88,
FELBAMATE,14032719,CDM,301,RC,80202,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
VANCOMYCIN LEVEL,14032720,CDM,301,RC,82710,HCPCS,Outpatient,,,212,212,,,,,,Other,Not Separately Reimbursable,60.57,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,60.57,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,154.76,73,,123.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.4,70,,118.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.68,19.19,,32.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,106,50,,84.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.68,154.76,
FECAL FAT QUANTITATIVE,14032721,CDM,301,RC,80177,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,43.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,43.73,82.5,,34.984,percent of total billed charges,Pays at 82.5% of total Billed charges,38.69,73,,30.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.1,70,,29.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,19.19,,8.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.5,50,,21.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,43.73,
LEVETRIACETAM (KEPPRA LEVEL),14032722,CDM,301,RC,86340,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
INTRINSIC FACTOR ANTIBODY,14032723,CDM,300,RC,86255,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
ANTIPARIETAL CELL AB,14032724,CDM,301,RC,80299,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
BACLOFEN (LIORESAL),14032725,CDM,301,RC,83520,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
NIACIN,14032726,CDM,301,RC,84590,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
"VITAMIN A, SERUM",14032727,CDM,301,RC,86666,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,47.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.85,82.5,,38.28,percent of total billed charges,Pays at 82.5% of total Billed charges,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,47.85,
EHRLICHIOSIS ANTIBODY AGENT,14032728,CDM,302,RC,81003,HCPCS,Outpatient,,,67,67,,,,,,Other,Not Separately Reimbursable,55.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,55.28,82.5,,44.224,percent of total billed charges,Pays at 82.5% of total Billed charges,48.91,73,,39.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,70,,37.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,19.19,,10.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.5,50,,26.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,55.28,
Automated urinalysis test,14032730,CDM,307,RC,84560,HCPCS,Outpatient,,,69,69,,,,,,Other,Not Separately Reimbursable,10.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,10.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,50.37,73,,40.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.3,70,,38.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.24,19.19,,10.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,50,,27.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.02,50.37,
URIC ACID 24 HR URINE,14032731,CDM,301,RC,86787,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,62.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,62.7,82.5,,50.16,percent of total billed charges,Pays at 82.5% of total Billed charges,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,62.7,
VARICELLA TITER,14032732,CDM,302,RC,82607,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
Blood test to measure B-12,14032733,CDM,301,RC,82652,HCPCS,Outpatient,,,133,133,,,,,,Other,Not Separately Reimbursable,67.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,67.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,97.09,73,,77.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.1,70,,74.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.52,19.19,,20.416,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,50,,53.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.52,97.09,
"VITAMIN D 1,25 DIHYDROXY",14032734,CDM,301,RC,87252,HCPCS,Outpatient,,,21.49,21.49,,,,,,Other,Not Separately Reimbursable,17.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,17.73,82.5,,14.184,percent of total billed charges,Pays at 82.5% of total Billed charges,15.69,73,,12.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.04,70,,12.032,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.12,19.19,,3.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,50,,8.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.12,17.73,
CULTURE (VIRAL),14032735,CDM,306,RC,82180,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,73.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,73.43,82.5,,58.744,percent of total billed charges,Pays at 82.5% of total Billed charges,64.97,73,,51.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.3,70,,49.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,19.19,,13.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.5,50,,35.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,73.43,
VITAMIN C (ASCORBIC ACID),14032736,CDM,301,RC,84446,HCPCS,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
VITAMIN E,14032737,CDM,301,RC,87046,HCPCS,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,47.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.03,82.5,,37.624,percent of total billed charges,Pays at 82.5% of total Billed charges,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,47.03,
CULTURE (STOOL VIBRIO ONLY),14032738,CDM,306,RC,82306,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,27.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.23,82.5,,21.784,percent of total billed charges,Pays at 82.5% of total Billed charges,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,27.23,
"VITAMIN D(1,25 DIHYDROXY/25-HYDROXY)PROF",14032739,CDM,301,RC,86652,HCPCS,Outpatient,,,34.49,34.49,,,,,,Other,Not Separately Reimbursable,28.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.45,82.5,,22.76,percent of total billed charges,Pays at 82.5% of total Billed charges,25.18,73,,20.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.14,70,,19.312,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.62,19.19,,5.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.25,50,,13.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.62,28.45,
"EAST EQU ENCEPH,IGM/CSF",14032740,CDM,306,RC,86790,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
WEST NILE AB PANEL,14032741,CDM,302,RC,87252,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
"TOXOCARA AB,SERUM",14032742,CDM,306,RC,87252,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,73.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,73.43,82.5,,58.744,percent of total billed charges,Pays at 82.5% of total Billed charges,64.97,73,,51.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.3,70,,49.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,19.19,,13.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.5,50,,35.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,73.43,
ARBOVIRUS CULTURE,14032743,CDM,306,RC,84156,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,73.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,73.43,82.5,,58.744,percent of total billed charges,Pays at 82.5% of total Billed charges,64.97,73,,51.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.3,70,,49.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,19.19,,13.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.5,50,,35.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,73.43,
PROTEIN 24 HOUR URINE,14032744,CDM,301,RC,84144,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,73.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,73.43,82.5,,58.744,percent of total billed charges,Pays at 82.5% of total Billed charges,64.97,73,,51.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.3,70,,49.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,19.19,,13.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.5,50,,35.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,73.43,
PROGESTERONE SERUM,14032745,CDM,301,RC,85302,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,93.27,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,93.27,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,64.24,73,,51.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,70,,49.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,19.19,,13.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44,50,,35.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,93.27,
PROTEIN C ANTIGEN,14032746,CDM,305,RC,84703,HCPCS,Outpatient,,,41,41,,,,,,Other,Not Separately Reimbursable,33.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33.83,82.5,,27.064,percent of total billed charges,Pays at 82.5% of total Billed charges,29.93,73,,23.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.7,70,,22.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,19.19,,6.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.5,50,,16.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,33.83,
Blood test to assess for pregnancy,14032748,CDM,301,RC,84703,HCPCS,Outpatient,,,128,128,,,,,,Other,Not Separately Reimbursable,33.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,33.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,93.44,73,,74.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.6,70,,71.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,19.19,,19.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64,50,,51.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,93.44,
Blood test to assess for pregnancy,14032749,CDM,301,RC,80192,HCPCS,Outpatient,,,128,128,,,,,,Other,Not Separately Reimbursable,33.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,33.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,93.44,73,,74.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.6,70,,71.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,19.19,,19.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64,50,,51.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,93.44,
PROCAINAMIDE,14032750,CDM,301,RC,80188,HCPCS,Outpatient,,,235,235,,,,,,Other,Not Separately Reimbursable,193.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,193.88,82.5,,155.104,percent of total billed charges,Pays at 82.5% of total Billed charges,171.55,73,,137.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,164.5,70,,131.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.1,19.19,,36.08,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.5,50,,94,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.1,193.88,
PRIMIDONE LEVEL,14032752,CDM,301,RC,83520,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
ANTIBODY TO GML GANGLIOSE,14032753,CDM,301,RC,84275,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
LIPID ASSOC SIALIC ACID,14032755,CDM,301,RC,80299,HCPCS,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,25.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,25.58,82.5,,20.464,percent of total billed charges,Pays at 82.5% of total Billed charges,22.63,73,,18.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.7,70,,17.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,19.19,,4.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.5,50,,12.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,25.58,
CLOZAPINE (CLOZARIL),14032756,CDM,301,RC,84545,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
UREA CLEAR-24HR URINE,14032757,CDM,301,RC,84311,HCPCS,Outpatient,,,108,108,,,,,,Other,Not Separately Reimbursable,29.52,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,29.52,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,78.84,73,,63.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75.6,70,,60.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.73,19.19,,16.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54,50,,43.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.73,78.84,
HEXOSAMINIDASE A DEFICIENCY,14032758,CDM,301,RC,83915,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
NUCLEOTIDASE 5 PRIME,14032759,CDM,301,RC,84153,HCPCS,Outpatient,,,72,72,,,,,,Other,Not Separately Reimbursable,59.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,59.4,82.5,,47.52,percent of total billed charges,Pays at 82.5% of total Billed charges,52.56,73,,42.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.4,70,,40.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,19.19,,11.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36,50,,28.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,59.4,
PSA (prostate specific antigen),14032760,CDM,301,RC,84144,HCPCS,Outpatient,,,201,201,,,,,,Other,Not Separately Reimbursable,82.25,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,82.25,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,146.73,73,,117.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140.7,70,,112.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.57,19.19,,30.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.5,50,,80.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.57,146.73,
PROGESTERONE URINE,14032761,CDM,301,RC,87808,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,72.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,72.6,82.5,,58.08,percent of total billed charges,Pays at 82.5% of total Billed charges,64.24,73,,51.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,70,,49.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,19.19,,13.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44,50,,35.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,72.6,
GROUP B STREP CULTURE VAGINAL,14032762,CDM,306,RC,86652,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
"E EQU ENCEPH,IGG/SERUM",14032763,CDM,306,RC,86652,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
E EQU ENCEPH IGM/SERUM,14032764,CDM,306,RC,84155,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
PROTEIN URINE RANDOM,14032765,CDM,301,RC,84066,HCPCS,Outpatient,,,43,43,,,,,,Other,Not Separately Reimbursable,16.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,16.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,31.39,73,,25.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.1,70,,24.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,19.19,,6.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.5,50,,17.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,31.39,
PROSTATIC ACID PHOS (PAP),14032766,CDM,301,RC,83915,HCPCS,Outpatient,,,41,41,,,,,,Other,Not Separately Reimbursable,33.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33.83,82.5,,27.064,percent of total billed charges,Pays at 82.5% of total Billed charges,29.93,73,,23.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.7,70,,22.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,19.19,,6.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.5,50,,16.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,33.83,
NUCLEOTIDASE 5,14032767,CDM,301,RC,82043,HCPCS,Outpatient,,,72,72,,,,,,Other,Not Separately Reimbursable,59.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,59.4,82.5,,47.52,percent of total billed charges,Pays at 82.5% of total Billed charges,52.56,73,,42.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.4,70,,40.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,19.19,,11.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36,50,,28.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,59.4,
MICROALBUMIN 24HR URINE,14032769,CDM,301,RC,82044,HCPCS,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,71.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,71.78,82.5,,57.424,percent of total billed charges,Pays at 82.5% of total Billed charges,63.51,73,,50.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.9,70,,48.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,19.19,,13.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.5,50,,34.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,71.78,
"MICROALBUMIN, RANDOM URINE",14032770,CDM,301,RC,82043,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,43.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,43.73,82.5,,34.984,percent of total billed charges,Pays at 82.5% of total Billed charges,38.69,73,,30.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.1,70,,29.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,19.19,,8.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.5,50,,21.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,43.73,
MICROALBUMIN/CREAT RANDOM URINE,14032772,CDM,301,RC,82608,HCPCS,Outpatient,,,8.14,8.14,,,,,,Other,Not Separately Reimbursable,6.72,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6.72,82.5,,5.376,percent of total billed charges,Pays at 82.5% of total Billed charges,5.94,73,,4.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.7,70,,4.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.56,19.19,,1.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.07,50,,3.256,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.56,6.72,
VITAMIN B12 UNSATURATED BINDING CAPACITY,14032773,CDM,301,RC,82306,HCPCS,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,123.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,123.75,82.5,,99,percent of total billed charges,Pays at 82.5% of total Billed charges,109.5,73,,87.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,70,,84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,19.19,,23.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75,50,,60,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,123.75,
Blood test to monitor vitamin D levels,14032774,CDM,301,RC,82652,HCPCS,Outpatient,,,105,105,,,,,,Other,Not Separately Reimbursable,132.33,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,132.33,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,76.65,73,,61.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.5,70,,58.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,19.19,,16.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,50,,42,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,132.33,
VITAMIN 25 DIHYDROXY TOTAL,14032776,CDM,301,RC,86787,HCPCS,Outpatient,,,132,132,,,,,,Other,Not Separately Reimbursable,108.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,108.9,82.5,,87.12,percent of total billed charges,Pays at 82.5% of total Billed charges,96.36,73,,77.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.4,70,,73.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.33,19.19,,20.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66,50,,52.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.33,108.9,
VARICELLA ANTIGEN DETECTION,14032777,CDM,302,RC,85303,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
PROTEIN C ACTIVITY,14032778,CDM,305,RC,85307,HCPCS,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,38.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,38.78,82.5,,31.024,percent of total billed charges,Pays at 82.5% of total Billed charges,34.31,73,,27.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.9,70,,26.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,19.19,,7.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.5,50,,18.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,38.78,
ACTIVATED PROTEIN C,14032779,CDM,305,RC,86652,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
"EAST EQU ENCEPH,IGM",14032780,CDM,306,RC,83789,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
"IODINE, URINE RANDOM",14032781,CDM,301,RC,84402,HCPCS,Outpatient,,,123,123,,,,,,Other,Not Separately Reimbursable,101.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,101.48,82.5,,81.184,percent of total billed charges,Pays at 82.5% of total Billed charges,89.79,73,,71.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.1,70,,68.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.6,19.19,,18.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.5,50,,49.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.6,101.48,
HIRSUTISM PROFILE,14032782,CDM,301,RC,80327,HCPCS,Outpatient,,,43,43,,,,,,Other,Not Separately Reimbursable,35.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,35.48,82.5,,28.384,percent of total billed charges,Pays at 82.5% of total Billed charges,31.39,73,,25.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.1,70,,24.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,19.19,,6.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.5,50,,17.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,35.48,
DIHYDROTESTOSTERONE,14032783,CDM,301,RC,84153,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,72.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,72.6,82.5,,58.08,percent of total billed charges,Pays at 82.5% of total Billed charges,64.24,73,,51.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,70,,49.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,19.19,,13.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44,50,,35.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,72.6,
PSA (prostate specific antigen),14032784,CDM,301,RC,82657,HCPCS,Outpatient,,,201,201,,,,,,Other,Not Separately Reimbursable,82.25,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,82.25,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,146.73,73,,117.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140.7,70,,112.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.57,19.19,,30.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.5,50,,80.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.57,146.73,
"ALPHA GALACTOSIDASE, SERUM",14032785,CDM,301,RC,83789,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
IODINE (EDTA),14032786,CDM,301,RC,83630,HCPCS,Outpatient,,,61.5,61.5,,,,,,Other,Not Separately Reimbursable,75.88,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,75.88,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,44.9,73,,35.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.05,70,,34.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.8,19.19,,9.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.75,50,,24.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.8,75.88,
LACTOFERRIN STOOL,14032788,CDM,301,RC,86768,HCPCS,Outpatient,,,155,155,,,,,,Other,Not Separately Reimbursable,127.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,127.88,82.5,,102.304,percent of total billed charges,Pays at 82.5% of total Billed charges,113.15,73,,90.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108.5,70,,86.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.74,19.19,,23.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.5,50,,62,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.74,127.88,
SALMONELLA TYPHI AB,14032789,CDM,302,RC,81050,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
URINE VOL MEASUREMENT,14032790,CDM,301,RC,86355,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,13.42,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,13.42,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,14.6,
B CELLS TOTAL,14032791,CDM,305,RC,86359,HCPCS,Outpatient,,,139,139,,,,,,Other,Not Separately Reimbursable,114.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,114.68,82.5,,91.744,percent of total billed charges,Pays at 82.5% of total Billed charges,101.47,73,,81.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.3,70,,77.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.67,19.19,,21.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.5,50,,55.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.67,114.68,
T CELLS TOTAL,14032792,CDM,305,RC,86360,HCPCS,Outpatient,,,139,139,,,,,,Other,Not Separately Reimbursable,114.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,114.68,82.5,,91.744,percent of total billed charges,Pays at 82.5% of total Billed charges,101.47,73,,81.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.3,70,,77.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.67,19.19,,21.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.5,50,,55.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.67,114.68,
ABSOLUTE CD4 & CD8 COUNT,14032793,CDM,305,RC,83516,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
GANGLIOSIDE PANEL,14032795,CDM,301,RC,83520,HCPCS,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,78.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,78.38,82.5,,62.704,percent of total billed charges,Pays at 82.5% of total Billed charges,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,78.38,
PANCREATIC ELASTASE FECAL QUANT,14032796,CDM,301,RC,84152,HCPCS,Outpatient,,,155,155,,,,,,Other,Not Separately Reimbursable,127.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,127.88,82.5,,102.304,percent of total billed charges,Pays at 82.5% of total Billed charges,113.15,73,,90.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108.5,70,,86.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.74,19.19,,23.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.5,50,,62,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.74,127.88,
PSA COMPLEX,14032800,CDM,302,RC,84152,HCPCS,Outpatient,,,117,117,,,,,,Other,Not Separately Reimbursable,96.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,96.53,82.5,,77.224,percent of total billed charges,Pays at 82.5% of total Billed charges,85.41,73,,68.328,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.9,70,,65.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.45,19.19,,17.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.5,50,,46.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.45,96.53,
OLANZAPINE,14032801,CDM,302,RC,83520,HCPCS,Outpatient,,,107.88,107.88,,,,,,Other,Not Separately Reimbursable,89,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,89,82.5,,71.2,percent of total billed charges,Pays at 82.5% of total Billed charges,78.75,73,,63,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75.52,70,,60.416,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.7,19.19,,16.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.94,50,,43.152,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.7,89,
ALPHA SUBUNIT,14032802,CDM,302,RC,83789,HCPCS,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,57.9,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,57.9,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,94.9,
ESTRONE SULFATE,14032803,CDM,302,RC,86618,HCPCS,Outpatient,,,175,175,,,,,,Other,Not Separately Reimbursable,75.88,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,75.88,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,127.75,73,,102.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.5,70,,98,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.58,19.19,,26.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,50,,70,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.58,127.75,
LYME TITER,14032804,CDM,302,RC,87177,HCPCS,Outpatient,,,8,8,,,,,,Other,Not Separately Reimbursable,65.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,5.84,73,,4.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.6,70,,4.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,19.19,,1.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4,50,,3.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,65.58,
O&P,14032805,CDM,306,RC,83525,HCPCS,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
INSULIN FREE AND TOTAL,14032806,CDM,302,RC,84140,HCPCS,Outpatient,,,20.18,20.18,,,,,,Other,Not Separately Reimbursable,51.12,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.12,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,14.73,73,,11.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.13,70,,11.304,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.87,19.19,,3.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.09,50,,8.072,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.87,51.12,
PREGNENOLONE,14032808,CDM,301,RC,84144,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,72.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,72.6,82.5,,58.08,percent of total billed charges,Pays at 82.5% of total Billed charges,64.24,73,,51.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,70,,49.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,19.19,,13.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44,50,,35.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,72.6,
PROGESTERONE FREE AND TOTAL,14032809,CDM,302,RC,82670,HCPCS,Outpatient,,,274.5,274.5,,,,,,Other,Not Separately Reimbursable,93.27,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,93.27,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,200.39,73,,160.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,192.15,70,,153.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.68,19.19,,42.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.25,50,,109.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.68,200.39,
ESTRADIOL,14032810,CDM,301,RC,82103,HCPCS,Outpatient,,,102,102,,,,,,Other,Not Separately Reimbursable,84.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,84.15,82.5,,67.32,percent of total billed charges,Pays at 82.5% of total Billed charges,74.46,73,,59.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.4,70,,57.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,19.19,,15.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51,50,,40.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,84.15,
ALPHA-1 ANTITRYPSIN PHENOTYPE,14032816,CDM,301,RC,82649,HCPCS,Outpatient,,,20.24,20.24,,,,,,Other,Not Separately Reimbursable,60.04,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,60.04,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,14.78,73,,11.824,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.17,70,,11.336,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.88,19.19,,3.104,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.12,50,,8.096,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.88,60.04,
HYDROMORPHONE,14032817,CDM,301,RC,82139,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,72.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,72.6,82.5,,58.08,percent of total billed charges,Pays at 82.5% of total Billed charges,64.24,73,,51.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,70,,49.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,19.19,,13.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44,50,,35.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,72.6,
AMINO ACID PROFILE QUANTITATIVE PLASMA,14032819,CDM,301,RC,82128,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
"AMINO ACIDS MULTIPLE, QUAL",14032820,CDM,301,RC,82150,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
AMYLASE,14032821,CDM,301,RC,82042,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,28.98,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,28.98,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,87.6,
ALBUMIN 24 HOUR URINE,14032825,CDM,301,RC,86038,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
ANA,14032830,CDM,302,RC,86038,HCPCS,Outpatient,,,18.04,18.04,,,,,,Other,Not Separately Reimbursable,14.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.88,82.5,,11.904,percent of total billed charges,Pays at 82.5% of total Billed charges,13.17,73,,10.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.63,70,,10.104,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.46,19.19,,2.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,50,,7.216,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.46,14.88,
ANA W/ REFLEX TO IMMUNOASSAY,14032831,CDM,302,RC,86039,HCPCS,Outpatient,,,4.4,4.4,,,,,,Other,Not Separately Reimbursable,54.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,3.21,73,,2.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.08,70,,2.464,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.84,19.19,,0.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.2,50,,1.76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.84,54.02,
ANA TITER,14032832,CDM,302,RC,83625,HCPCS,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,38.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,38.78,82.5,,31.024,percent of total billed charges,Pays at 82.5% of total Billed charges,34.31,73,,27.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.9,70,,26.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,19.19,,7.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.5,50,,18.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,38.78,
LDH ISOENZYMES,14032839,CDM,301,RC,82150,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
AMYLASE ISOENZYMES,14032840,CDM,301,RC,82550,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
CK ISOENZYMES,14032841,CDM,301,RC,82553,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,75.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,75.9,82.5,,60.72,percent of total billed charges,Pays at 82.5% of total Billed charges,67.16,73,,53.728,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.4,70,,51.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,19.19,,14.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46,50,,36.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,75.9,
Blood test to detect heart enzymes,14032847,CDM,301,RC,81001,HCPCS,Outpatient,,,148,148,,,,,,Other,Not Separately Reimbursable,40.51,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,40.51,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,108.04,73,,86.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.6,70,,82.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.4,19.19,,22.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74,50,,59.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.4,108.04,
Manual urinalysis test with examination with or without using microscope,14032850,CDM,307,RC,82626,HCPCS,Outpatient,,,96,96,,,,,,Other,Not Separately Reimbursable,14.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,14.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,70.08,73,,56.064,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.2,70,,53.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,19.19,,14.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48,50,,38.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.14,70.08,
DHEA URINE,14032861,CDM,301,RC,80162,HCPCS,Outpatient,,,145,145,,,,,,Other,Not Separately Reimbursable,119.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,119.63,82.5,,95.704,percent of total billed charges,Pays at 82.5% of total Billed charges,105.85,73,,84.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.5,70,,81.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.83,19.19,,22.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.5,50,,58,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.83,119.63,
DIGOXIN LEVEL,14032862,CDM,301,RC,83519,HCPCS,Outpatient,,,119,119,,,,,,Other,Not Separately Reimbursable,59.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,59.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,86.87,73,,69.496,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.3,70,,66.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.84,19.19,,18.272,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,50,,47.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.84,86.87,
DIGITOXIN LEVEL,14032863,CDM,301,RC,87798,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,170.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,170.78,82.5,,136.624,percent of total billed charges,Pays at 82.5% of total Billed charges,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,170.78,
"EHRLICHIA PANEL,DNA BY PCR",14032864,CDM,306,RC,86904,HCPCS,Outpatient,,,317,317,,,,,,Other,Not Separately Reimbursable,261.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,261.53,82.5,,209.224,percent of total billed charges,Pays at 82.5% of total Billed charges,231.41,73,,185.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,221.9,70,,177.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.83,19.19,,48.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,158.5,50,,126.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.83,261.53,
ANTG SC PT SERUM EA,14032867,CDM,302,RC,86902,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,42.49,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,42.49,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,42.49,
ANTG SC REAGENT EA,14032868,CDM,302,RC,86870,HCPCS,Outpatient,,,44,44,,,,,,Other,Not Separately Reimbursable,26.37,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,26.37,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,32.12,73,,25.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.8,70,,24.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,19.19,,6.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22,50,,17.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,32.12,
ANTIBODY ID,14032869,CDM,302,RC,86920,HCPCS,Outpatient,,,225,225,,,,,,Other,Not Separately Reimbursable,185.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,185.63,82.5,,148.504,percent of total billed charges,Pays at 82.5% of total Billed charges,164.25,73,,131.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.5,70,,126,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,19.19,,34.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112.5,50,,90,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,185.63,
CROSSMATCH,14032870,CDM,302,RC,86900,HCPCS,Outpatient,,,205,205,,,,,,Other,Not Separately Reimbursable,169.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,169.13,82.5,,135.304,percent of total billed charges,Pays at 82.5% of total Billed charges,149.65,73,,119.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.5,70,,114.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,19.19,,31.472,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.5,50,,82,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,169.13,
ABO GROUP,14032871,CDM,302,RC,86901,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,13.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,13.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,25.55,73,,20.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,70,,19.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,19.19,,5.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,50,,14,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,25.55,
RH (D) TYPING,14032872,CDM,302,RC,86920,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,28.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.88,82.5,,23.104,percent of total billed charges,Pays at 82.5% of total Billed charges,25.55,73,,20.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,70,,19.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,19.19,,5.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,50,,14,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,28.88,
COMPATIBILITY IMMEDIATE SPIN,14032873,CDM,302,RC,86921,HCPCS,Outpatient,,,205,205,,,,,,Other,Not Separately Reimbursable,169.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,169.13,82.5,,135.304,percent of total billed charges,Pays at 82.5% of total Billed charges,149.65,73,,119.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.5,70,,114.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,19.19,,31.472,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.5,50,,82,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,169.13,
COMPATIBILITY INCUBATION,14032874,CDM,302,RC,86922,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,28.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.88,82.5,,23.104,percent of total billed charges,Pays at 82.5% of total Billed charges,25.55,73,,20.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,70,,19.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,19.19,,5.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,50,,14,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,28.88,
COMPATIBILITY ANTIGLOBULIN,14032875,CDM,302,RC,86850,HCPCS,Outpatient,,,116,116,,,,,,Other,Not Separately Reimbursable,95.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,95.7,82.5,,76.56,percent of total billed charges,Pays at 82.5% of total Billed charges,84.68,73,,67.744,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.2,70,,64.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.26,19.19,,17.808,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58,50,,46.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.26,95.7,
Blood test to screen for antibodies that could harm red blood cells,14032876,CDM,302,RC,81327,HCPCS,Outpatient,,,109,109,,,,,,Other,Not Separately Reimbursable,89.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,89.93,82.5,,71.944,percent of total billed charges,Pays at 82.5% of total Billed charges,79.57,73,,63.656,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.3,70,,61.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.92,19.19,,16.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.5,50,,43.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.92,89.93,
COLOVANTAGE,14032881,CDM,302,RC,86317,HCPCS,Outpatient,,,275,275,,,,,,Other,Not Separately Reimbursable,226.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,226.88,82.5,,181.504,percent of total billed charges,Pays at 82.5% of total Billed charges,200.75,73,,160.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,192.5,70,,154,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.77,19.19,,42.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.5,50,,110,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.77,226.88,
TETANUS ANTIBODY,14032885,CDM,302,RC,86317,HCPCS,Outpatient,,,63,63,,,,,,Other,Not Separately Reimbursable,51.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,51.98,82.5,,41.584,percent of total billed charges,Pays at 82.5% of total Billed charges,45.99,73,,36.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.1,70,,35.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,19.19,,9.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,50,,25.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,51.98,
DIPTHERIA ANTIBODY,14032886,CDM,302,RC,86648,HCPCS,Outpatient,,,63,63,,,,,,Other,Not Separately Reimbursable,51.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,51.98,82.5,,41.584,percent of total billed charges,Pays at 82.5% of total Billed charges,45.99,73,,36.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.1,70,,35.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,19.19,,9.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,50,,25.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,51.98,
DIPTHERIA ANTIBODY,14032887,CDM,302,RC,86940,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
ISOHEMAGGLUTININ TITER,14032889,CDM,302,RC,84252,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,28.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.88,82.5,,23.104,percent of total billed charges,Pays at 82.5% of total Billed charges,25.55,73,,20.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,70,,19.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,19.19,,5.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,50,,14,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,28.88,
VITAMIN B2 (RIBOLAVIN),14032892,CDM,301,RC,84207,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
VITAMIN B6 (PYRIDOXAL PHOSPHATE),14032893,CDM,301,RC,80320,HCPCS,Outpatient,,,79,79,,,,,,Other,Not Separately Reimbursable,65.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,65.18,82.5,,52.144,percent of total billed charges,Pays at 82.5% of total Billed charges,57.67,73,,46.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.3,70,,44.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,19.19,,12.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.5,50,,31.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,65.18,
ALCOHOL URINE,14032894,CDM,301,RC,80299,HCPCS,Outpatient,,,270,270,,,,,,Other,Not Separately Reimbursable,222.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,222.75,82.5,,178.2,percent of total billed charges,Pays at 82.5% of total Billed charges,197.1,73,,157.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,189,70,,151.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.81,19.19,,41.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,135,50,,108,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.81,222.75,
FLECAINIDE,14032895,CDM,301,RC,80198,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
THEOPHYLLINE LEVEL,14032896,CDM,301,RC,80299,HCPCS,Outpatient,,,162,162,,,,,,Other,Not Separately Reimbursable,63.28,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,63.28,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,118.26,73,,94.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,113.4,70,,90.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.09,19.19,,24.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81,50,,64.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.09,118.26,
THIOTHIXENE (NAVANE),14032898,CDM,301,RC,84425,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
VITAMIN B1 (THIAMINE),14032899,CDM,301,RC,80185,HCPCS,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,38.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,38.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,13.14,73,,10.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,70,,10.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,19.19,,2.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9,50,,7.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,38.08,
DILANTIN LEVEL,14032900,CDM,301,RC,84134,HCPCS,Outpatient,,,215,215,,,,,,Other,Not Separately Reimbursable,59.28,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,59.28,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,156.95,73,,125.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,150.5,70,,120.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.26,19.19,,33.008,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.5,50,,86,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.26,156.95,
Blood test to measure level of prealbumin,14032902,CDM,301,RC,80300,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,65.21,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.21,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,48.18,73,,38.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.2,70,,36.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,19.19,,10.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33,50,,26.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,65.21,
DRUG SC/CHAIN OF CUSTODY,14032905,CDM,301,RC,82679,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
ESTRONE,14032907,CDM,301,RC,82670,HCPCS,Outpatient,,,98,98,,,,,,Other,Not Separately Reimbursable,80.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,80.85,82.5,,64.68,percent of total billed charges,Pays at 82.5% of total Billed charges,71.54,73,,57.232,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.6,70,,54.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.81,19.19,,15.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,50,,39.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.81,80.85,
ESTRADIOL LAB CORP,14032908,CDM,301,RC,82157,HCPCS,Outpatient,,,22.44,22.44,,,,,,Other,Not Separately Reimbursable,18.51,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.51,82.5,,14.808,percent of total billed charges,Pays at 82.5% of total Billed charges,16.38,73,,13.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.71,70,,12.568,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.31,19.19,,3.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.22,50,,8.976,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.31,18.51,
ANDROSTENEDIONE,14032909,CDM,301,RC,86341,HCPCS,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
"TYROSINE,QUAN/PLASMA",14032910,CDM,301,RC,82270,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
OCCULT BLOOD SCREENING,14032911,CDM,301,RC,82272,HCPCS,Outpatient,,,63,63,,,,,,Other,Not Separately Reimbursable,11.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,11.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,45.99,73,,36.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.1,70,,35.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,19.19,,9.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,50,,25.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.31,45.99,
OCCULT BLOOD STOOL (GUIAC),14032912,CDM,301,RC,80076,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
Liver function blood test panel,14032913,CDM,301,RC,80069,HCPCS,Outpatient,,,125,125,,,,,,Other,Not Separately Reimbursable,35.56,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,35.56,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,91.25,73,,73,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,70,,70,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,19.19,,19.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.5,50,,50,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,91.25,
Kidney function panel test,14032914,CDM,301,RC,82140,HCPCS,Outpatient,,,132,132,,,,,,Other,Not Separately Reimbursable,108.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,108.9,82.5,,87.12,percent of total billed charges,Pays at 82.5% of total Billed charges,96.36,73,,77.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.4,70,,73.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.33,19.19,,20.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66,50,,52.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.33,108.9,
AMMONIA LEVEL,14032915,CDM,301,RC,84030,HCPCS,Outpatient,,,153,153,,,,,,Other,Not Separately Reimbursable,126.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,126.23,82.5,,100.984,percent of total billed charges,Pays at 82.5% of total Billed charges,111.69,73,,89.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.1,70,,85.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.36,19.19,,23.488,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.5,50,,61.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.36,126.23,
"PHENYLALANINE,QUANT/PLASMA",14032916,CDM,301,RC,86644,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
Blood test to monitor for cytomegalovirus,14032917,CDM,302,RC,82164,HCPCS,Outpatient,,,61,61,,,,,,Other,Not Separately Reimbursable,64.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,64.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,44.53,73,,35.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.7,70,,34.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,19.19,,9.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.5,50,,24.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,64.35,
ACE ANGIOTENSIN,14032919,CDM,301,RC,80076,HCPCS,Outpatient,,,62,62,,,,,,Other,Not Separately Reimbursable,51.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,51.15,82.5,,40.92,percent of total billed charges,Pays at 82.5% of total Billed charges,45.26,73,,36.208,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.4,70,,34.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,19.19,,9.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31,50,,24.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,51.15,
Liver function blood test panel,14032920,CDM,301,RC,89050,HCPCS,Outpatient,,,125,125,,,,,,Other,Not Separately Reimbursable,35.56,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,35.56,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,91.25,73,,73,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,70,,70,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,19.19,,19.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.5,50,,50,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,91.25,
CELL COUNT BODY FLUID,14032921,CDM,300,RC,83655,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
LEAD LEVEL,14032922,CDM,301,RC,83825,HCPCS,Outpatient,,,13.86,13.86,,,,,,Other,Not Separately Reimbursable,11.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.43,82.5,,9.144,percent of total billed charges,Pays at 82.5% of total Billed charges,10.12,73,,8.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.7,70,,7.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.66,19.19,,2.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.93,50,,5.544,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.66,11.43,
"MERCURY LEVEL, BLOOD",14032923,CDM,301,RC,82175,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
ARSENIC LEVEL BLOOD,14032924,CDM,301,RC,83935,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
OSMOLALITY URINE RANDOM,14032925,CDM,301,RC,86677,HCPCS,Outpatient,,,79,79,,,,,,Other,Not Separately Reimbursable,65.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,65.18,82.5,,52.144,percent of total billed charges,Pays at 82.5% of total Billed charges,57.67,73,,46.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.3,70,,44.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,19.19,,12.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.5,50,,31.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,65.18,
Blood test to if peptic ulcers are caused by a certain bacterium,14032926,CDM,302,RC,87338,HCPCS,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.89,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,64.89,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.89,
"H PYLORI AG,STOOL",14032927,CDM,306,RC,86812,HCPCS,Outpatient,,,33.51,33.51,,,,,,Other,Not Separately Reimbursable,27.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.65,82.5,,22.12,percent of total billed charges,Pays at 82.5% of total Billed charges,24.46,73,,19.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.46,70,,18.768,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.43,19.19,,5.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.76,50,,13.408,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.43,27.65,
HLA-B27,14032928,CDM,302,RC,80299,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,72.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,72.6,82.5,,58.08,percent of total billed charges,Pays at 82.5% of total Billed charges,64.24,73,,51.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,70,,49.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,19.19,,13.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44,50,,35.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,72.6,
LAMOTRIGINE (LAMICIAL),14032929,CDM,301,RC,83930,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
OSMOLALITY SERUM,14032930,CDM,301,RC,82945,HCPCS,Outpatient,,,101,101,,,,,,Other,Not Separately Reimbursable,83.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,83.33,82.5,,66.664,percent of total billed charges,Pays at 82.5% of total Billed charges,73.73,73,,58.984,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.7,70,,56.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,19.19,,15.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.5,50,,40.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,83.33,
GLUCOSE BODY FL QUANT,14032931,CDM,301,RC,84238,HCPCS,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
ACETYLCHOLINE BLOCKING (AchR),14032932,CDM,301,RC,84238,HCPCS,Outpatient,,,125,125,,,,,,Other,Not Separately Reimbursable,103.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,103.13,82.5,,82.504,percent of total billed charges,Pays at 82.5% of total Billed charges,91.25,73,,73,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,70,,70,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,19.19,,19.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.5,50,,50,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,103.13,
ACETYLCHOLINE BINDING (AchR),14032933,CDM,301,RC,86849,HCPCS,Outpatient,,,125,125,,,,,,Other,Not Separately Reimbursable,103.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,103.13,82.5,,82.504,percent of total billed charges,Pays at 82.5% of total Billed charges,91.25,73,,73,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,70,,70,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,19.19,,19.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.5,50,,50,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,103.13,
SENSORIMOTOR NEUROPATHY PANEL,14032934,CDM,302,RC,87400,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,72.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,72.6,82.5,,58.08,percent of total billed charges,Pays at 82.5% of total Billed charges,64.24,73,,51.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,70,,49.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,19.19,,13.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44,50,,35.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,72.6,
INFLUENZA A&B RAPID TEST,14032935,CDM,302,RC,86677,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
H PYLORI IgG,14032936,CDM,301,RC,86677,HCPCS,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
H PYLORI IgG/IgM/IgA,14032937,CDM,301,RC,83013,HCPCS,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
Test of breath for a stomach bacterium,14032938,CDM,301,RC,86817,HCPCS,Outpatient,,,13.86,13.86,,,,,,Other,Not Separately Reimbursable,279.72,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,279.72,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,10.12,73,,8.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.7,70,,7.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.66,19.19,,2.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.93,50,,5.544,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.66,279.72,
HLA:DR COMPLETE,14032939,CDM,302,RC,87400,HCPCS,Outpatient,,,221,221,,,,,,Other,Not Separately Reimbursable,182.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,182.33,82.5,,145.864,percent of total billed charges,Pays at 82.5% of total Billed charges,161.33,73,,129.064,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154.7,70,,123.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.41,19.19,,33.928,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110.5,50,,88.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.41,182.33,
INFLUENZA B RAPID TEST,14032940,CDM,302,RC,84155,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
PROTEIN BODY FLUID,14032941,CDM,301,RC,85305,HCPCS,Outpatient,,,43,43,,,,,,Other,Not Separately Reimbursable,16.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,16.38,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,31.39,73,,25.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.1,70,,24.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,19.19,,6.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.5,50,,17.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,31.39,
PROTEIN S ANTIGEN,14032943,CDM,305,RC,83519,HCPCS,Outpatient,,,49,49,,,,,,Other,Not Separately Reimbursable,40.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,40.43,82.5,,32.344,percent of total billed charges,Pays at 82.5% of total Billed charges,35.77,73,,28.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.3,70,,27.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,19.19,,7.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,50,,19.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,40.43,
ACETYLCHOLINE RECEPTOR BLOCKING ABS,14032944,CDM,301,RC,85300,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,170.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,170.78,82.5,,136.624,percent of total billed charges,Pays at 82.5% of total Billed charges,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,170.78,
ANTI-THROMBIN III LEVEL,14032945,CDM,305,RC,86317,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,27.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.23,82.5,,21.784,percent of total billed charges,Pays at 82.5% of total Billed charges,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,27.23,
LE PREP ANTI DNP ABS,14032946,CDM,302,RC,84134,HCPCS,Outpatient,,,63,63,,,,,,Other,Not Separately Reimbursable,51.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,51.98,82.5,,41.584,percent of total billed charges,Pays at 82.5% of total Billed charges,45.99,73,,36.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.1,70,,35.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,19.19,,9.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,50,,25.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,51.98,
TYPTASE,14032947,CDM,301,RC,82300,HCPCS,Outpatient,,,62,62,,,,,,Other,Not Separately Reimbursable,51.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,51.15,82.5,,40.92,percent of total billed charges,Pays at 82.5% of total Billed charges,45.26,73,,36.208,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.4,70,,34.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,19.19,,9.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31,50,,24.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,51.15,
CADMIUM,14032948,CDM,301,RC,87497,HCPCS,Outpatient,,,102,102,,,,,,Other,Not Separately Reimbursable,84.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,84.15,82.5,,67.32,percent of total billed charges,Pays at 82.5% of total Billed charges,74.46,73,,59.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.4,70,,57.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,19.19,,15.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51,50,,40.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,84.15,
CYTOMEGALOVIRUS DNA BY PCR,14032949,CDM,306,RC,89300,HCPCS,Outpatient,,,210,210,,,,,,Other,Not Separately Reimbursable,173.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,173.25,82.5,,138.6,percent of total billed charges,Pays at 82.5% of total Billed charges,153.3,73,,122.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,70,,117.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,19.19,,32.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,50,,84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,173.25,
SPERM COUNT POST VAS,14032950,CDM,300,RC,87070,HCPCS,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,31.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,31.35,82.5,,25.08,percent of total billed charges,Pays at 82.5% of total Billed charges,27.74,73,,22.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.6,70,,21.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,19.19,,5.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,50,,15.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,31.35,
Test of body fluid other than blood to assess for bacteria,14032951,CDM,306,RC,86157,HCPCS,Outpatient,,,29.26,29.26,,,,,,Other,Not Separately Reimbursable,38.49,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,38.49,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,21.36,73,,17.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.48,70,,16.384,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.61,19.19,,4.488,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.63,50,,11.704,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.61,38.49,
COLD AGGLUTININS,14032953,CDM,302,RC,86157,HCPCS,Outpatient,,,34,34,,,,,,Other,Not Separately Reimbursable,28.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.05,82.5,,22.44,percent of total billed charges,Pays at 82.5% of total Billed charges,24.82,73,,19.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,70,,19.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,19.19,,5.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17,50,,13.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,28.05,
"OSMOTIC FRAGILITY, RBC",14032954,CDM,302,RC,89320,HCPCS,Outpatient,,,34,34,,,,,,Other,Not Separately Reimbursable,28.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.05,82.5,,22.44,percent of total billed charges,Pays at 82.5% of total Billed charges,24.82,73,,19.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,70,,19.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,19.19,,5.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17,50,,13.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,28.05,
SPERM COUNT TOTAL,14032955,CDM,300,RC,82271,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
OCCULT BLOOD (GASTRIC),14032957,CDM,301,RC,82270,HCPCS,Outpatient,,,63,63,,,,,,Other,Not Separately Reimbursable,14.52,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,14.52,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,45.99,73,,36.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.1,70,,35.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,19.19,,9.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,50,,25.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,45.99,
OCCULT BLOOD (DRAINAGE),14032958,CDM,301,RC,82533,HCPCS,Outpatient,,,63,63,,,,,,Other,Not Separately Reimbursable,11.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,11.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,45.99,73,,36.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.1,70,,35.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,19.19,,9.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,50,,25.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.31,45.99,
CORTISOL SERUM,14032960,CDM,301,RC,,,Outpatient,,,16.28,16.28,,,,,,Other,Not Separately Reimbursable,13.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13.43,82.5,,10.744,percent of total billed charges,Pays at 82.5% of total Billed charges,11.88,73,,9.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.4,70,,9.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.12,19.19,,2.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.14,50,,6.512,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.12,13.43,
VET FRUCTOSAMINE,14032961,CDM,301,RC,84449,HCPCS,Outpatient,,,16,16,,,,,,Other,Not Separately Reimbursable,13.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13.2,82.5,,10.56,percent of total billed charges,Pays at 82.5% of total Billed charges,11.68,73,,9.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.2,70,,8.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,19.19,,2.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8,50,,6.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,13.2,
"FREE CORTISOL, SERUM",14032962,CDM,301,RC,82340,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
CALCIUM-URINE 24 HR,14032964,CDM,301,RC,84681,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
C-PEPTIDE,14032965,CDM,301,RC,86360,HCPCS,Outpatient,,,19.14,19.14,,,,,,Other,Not Separately Reimbursable,15.79,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,15.79,82.5,,12.632,percent of total billed charges,Pays at 82.5% of total Billed charges,13.97,73,,11.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.4,70,,10.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.67,19.19,,2.936,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.57,50,,7.656,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.67,15.79,
CD8-T-CELLS,14032966,CDM,302,RC,82523,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
N-TELOPEPTIDE (URINE),14032967,CDM,301,RC,82523,HCPCS,Outpatient,,,79,79,,,,,,Other,Not Separately Reimbursable,65.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,65.18,82.5,,52.144,percent of total billed charges,Pays at 82.5% of total Billed charges,57.67,73,,46.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.3,70,,44.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,19.19,,12.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.5,50,,31.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,65.18,
N-TELOPEPTIDE CROSS LINKS,14032968,CDM,301,RC,87045,HCPCS,Outpatient,,,79,79,,,,,,Other,Not Separately Reimbursable,65.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,65.18,82.5,,52.144,percent of total billed charges,Pays at 82.5% of total Billed charges,57.67,73,,46.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.3,70,,44.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,19.19,,12.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.5,50,,31.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,65.18,
CULTURE (STOOL),14032979,CDM,306,RC,87081,HCPCS,Outpatient,,,18.7,18.7,,,,,,Other,Not Separately Reimbursable,15.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,15.43,82.5,,12.344,percent of total billed charges,Pays at 82.5% of total Billed charges,13.65,73,,10.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.09,70,,10.472,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.59,19.19,,2.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.35,50,,7.48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.59,15.43,
YERSINIA [STOOL],14032980,CDM,306,RC,87040,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,47.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.85,82.5,,38.28,percent of total billed charges,Pays at 82.5% of total Billed charges,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,47.85,
CULTURE (BLOOD) BACTERIAL,14032987,CDM,306,RC,82239,HCPCS,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,9.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.08,82.5,,7.264,percent of total billed charges,Pays at 82.5% of total Billed charges,8.03,73,,6.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.7,70,,6.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,19.19,,1.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.5,50,,4.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,9.08,
BILE ACIDS,14032988,CDM,301,RC,83935,HCPCS,Outpatient,,,72,72,,,,,,Other,Not Separately Reimbursable,59.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,59.4,82.5,,47.52,percent of total billed charges,Pays at 82.5% of total Billed charges,52.56,73,,42.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.4,70,,40.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,19.19,,11.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36,50,,28.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,59.4,
OSMOLALITY URINE 24 HR,14032989,CDM,301,RC,87899,HCPCS,Outpatient,,,79,79,,,,,,Other,Not Separately Reimbursable,65.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,65.18,82.5,,52.144,percent of total billed charges,Pays at 82.5% of total Billed charges,57.67,73,,46.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.3,70,,44.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,19.19,,12.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.5,50,,31.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,65.18,
BACTERIAL ANTIGENS,14032990,CDM,306,RC,,,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
VET CULTURE,14032991,CDM,300,RC,,,Outpatient,,,36.5,36.5,,,,,,Other,Not Separately Reimbursable,30.11,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,30.11,82.5,,24.088,percent of total billed charges,Pays at 82.5% of total Billed charges,26.65,73,,21.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.55,70,,20.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,19.19,,5.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.25,50,,14.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,30.11,
VET CULTURE IDENTIFICATION,14032992,CDM,300,RC,,,Outpatient,,,1.9,1.9,,,,,,Other,Not Separately Reimbursable,1.57,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1.57,82.5,,1.256,percent of total billed charges,Pays at 82.5% of total Billed charges,1.39,73,,1.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.33,70,,1.064,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.36,19.19,,0.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.95,50,,0.76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.36,1.57,
VET CULTURE SENSITIVITY,14032993,CDM,300,RC,87070,HCPCS,Outpatient,,,19.5,19.5,,,,,,Other,Not Separately Reimbursable,16.09,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.09,82.5,,12.872,percent of total billed charges,Pays at 82.5% of total Billed charges,14.24,73,,11.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.65,70,,10.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.74,19.19,,2.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.75,50,,7.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.74,16.09,
CULTURE (ENVIROMENTAL),14032994,CDM,306,RC,87070,HCPCS,Outpatient,,,218,218,,,,,,Other,Not Separately Reimbursable,179.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,179.85,82.5,,143.88,percent of total billed charges,Pays at 82.5% of total Billed charges,159.14,73,,127.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,152.6,70,,122.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.83,19.19,,33.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109,50,,87.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.83,179.85,
CULTURE Aerobic & Anaerobic,14032995,CDM,306,RC,87070,HCPCS,Outpatient,,,34.6,34.6,,,,,,Other,Not Separately Reimbursable,28.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.55,82.5,,22.84,percent of total billed charges,Pays at 82.5% of total Billed charges,25.26,73,,20.208,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.22,70,,19.376,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.64,19.19,,5.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.3,50,,13.84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.64,28.55,
CULTURE ANAEROBIC,14032996,CDM,306,RC,87077,HCPCS,Outpatient,,,34.6,34.6,,,,,,Other,Not Separately Reimbursable,28.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.55,82.5,,22.84,percent of total billed charges,Pays at 82.5% of total Billed charges,25.26,73,,20.208,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.22,70,,19.376,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.64,19.19,,5.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.3,50,,13.84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.64,28.55,
CULTURE IDENTIFICATION,14032997,CDM,306,RC,87186,HCPCS,Outpatient,,,5.72,5.72,,,,,,Other,Not Separately Reimbursable,4.72,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.72,82.5,,3.776,percent of total billed charges,Pays at 82.5% of total Billed charges,4.18,73,,3.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4,70,,3.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.1,19.19,,0.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.86,50,,2.288,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.1,4.72,
CULTURE SENSITIVITY,14032998,CDM,306,RC,87070,HCPCS,Outpatient,,,7.5,7.5,,,,,,Other,Not Separately Reimbursable,6.19,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6.19,82.5,,4.952,percent of total billed charges,Pays at 82.5% of total Billed charges,5.48,73,,4.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.25,70,,4.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.44,19.19,,1.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.75,50,,3,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.44,6.19,
Test of body fluid other than blood to assess for bacteria,14032999,CDM,306,RC,86645,HCPCS,Outpatient,,,34.6,34.6,,,,,,Other,Not Separately Reimbursable,38.49,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,38.49,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,25.26,73,,20.208,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.22,70,,19.376,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.64,19.19,,5.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.3,50,,13.84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.64,38.49,
CMV ANTIBODY IGM,14033000,CDM,302,RC,87086,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,75.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,75.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,75.32,
CULTURE (URINE),14033001,CDM,306,RC,84588,HCPCS,Outpatient,,,7.75,7.75,,,,,,Other,Not Separately Reimbursable,6.39,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6.39,82.5,,5.112,percent of total billed charges,Pays at 82.5% of total Billed charges,5.66,73,,4.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.43,70,,4.344,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.49,19.19,,1.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.88,50,,3.104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.49,6.39,
VASOPRESSIN (ADH),14033002,CDM,301,RC,82131,HCPCS,Outpatient,,,116,116,,,,,,Other,Not Separately Reimbursable,151.77,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,151.77,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,84.68,73,,67.744,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.2,70,,64.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.26,19.19,,17.808,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58,50,,46.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.26,151.77,
CHROMOGRANIN A,14033003,CDM,301,RC,86022,HCPCS,Outpatient,,,214,214,,,,,,Other,Not Separately Reimbursable,176.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,176.55,82.5,,141.24,percent of total billed charges,Pays at 82.5% of total Billed charges,156.22,73,,124.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.8,70,,119.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.07,19.19,,32.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107,50,,85.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.07,176.55,
ANTI-PLATELET,14033004,CDM,302,RC,86256,HCPCS,Outpatient,,,216,216,,,,,,Other,Not Separately Reimbursable,178.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,178.2,82.5,,142.56,percent of total billed charges,Pays at 82.5% of total Billed charges,157.68,73,,126.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.2,70,,120.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.45,19.19,,33.16,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108,50,,86.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.45,178.2,
TITER-EACH ANTIODY,14033005,CDM,302,RC,86235,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
ANTI EXT NUCLEAR AG,14033006,CDM,302,RC,86671,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,62.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,62.7,82.5,,50.16,percent of total billed charges,Pays at 82.5% of total Billed charges,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,62.7,
SACCHAROMYCES CEREVISIAE PROFILE (ASCA),14033007,CDM,302,RC,89325,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
SPERM ANTIBODY TEST,14033008,CDM,300,RC,83519,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
NEUROKININ-A,14033009,CDM,301,RC,83519,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,170.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,170.78,82.5,,136.624,percent of total billed charges,Pays at 82.5% of total Billed charges,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,170.78,
PANCREASTATON,14033011,CDM,301,RC,83520,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,170.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,170.78,82.5,,136.624,percent of total billed charges,Pays at 82.5% of total Billed charges,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,170.78,
ANTI RNA POLYMERASE,14033012,CDM,302,RC,86255,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
CENTROMERE AUTOANTIBODIES,14033013,CDM,302,RC,86235,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
SCL-70 IGG AUTOANTIBODIES,14033014,CDM,302,RC,86060,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,62.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,62.7,82.5,,50.16,percent of total billed charges,Pays at 82.5% of total Billed charges,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,62.7,
ASO-TITER,14033015,CDM,302,RC,82024,HCPCS,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,25.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,25.58,82.5,,20.464,percent of total billed charges,Pays at 82.5% of total Billed charges,22.63,73,,18.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.7,70,,17.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,19.19,,4.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.5,50,,12.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,25.58,
ATCH,14033016,CDM,301,RC,84586,HCPCS,Outpatient,,,132,132,,,,,,Other,Not Separately Reimbursable,108.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,108.9,82.5,,87.12,percent of total billed charges,Pays at 82.5% of total Billed charges,96.36,73,,77.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.4,70,,73.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.33,19.19,,20.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66,50,,52.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.33,108.9,
PANCREATIC POLYPEPTIDE,14033017,CDM,301,RC,82943,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
"GLUCAGON, PLASMA",14033018,CDM,301,RC,87081,HCPCS,Outpatient,,,128,128,,,,,,Other,Not Separately Reimbursable,105.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,105.6,82.5,,84.48,percent of total billed charges,Pays at 82.5% of total Billed charges,93.44,73,,74.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.6,70,,71.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,19.19,,19.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64,50,,51.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,105.6,
CULTURE SCREEN ONLY,14033019,CDM,306,RC,82955,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,47.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.85,82.5,,38.28,percent of total billed charges,Pays at 82.5% of total Billed charges,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,47.85,
G6PD,14033020,CDM,301,RC,87081,HCPCS,Outpatient,,,41,41,,,,,,Other,Not Separately Reimbursable,33.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33.83,82.5,,27.064,percent of total billed charges,Pays at 82.5% of total Billed charges,29.93,73,,23.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.7,70,,22.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,19.19,,6.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.5,50,,16.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,33.83,
Medical test to find an infection,14033021,CDM,302,RC,86674,HCPCS,Outpatient,,,136,136,,,,,,Other,Not Separately Reimbursable,29.64,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,29.64,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,99.28,73,,79.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.2,70,,76.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.1,19.19,,20.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68,50,,54.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.1,99.28,
GIARDIA ANTIBODIES,14033022,CDM,302,RC,87329,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
GIARDIA STOOL (EIA),14033023,CDM,306,RC,87230,HCPCS,Outpatient,,,16.41,16.41,,,,,,Other,Not Separately Reimbursable,13.54,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13.54,82.5,,10.832,percent of total billed charges,Pays at 82.5% of total Billed charges,11.98,73,,9.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.49,70,,9.192,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.15,19.19,,2.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.21,50,,6.568,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.15,13.54,
CLOSTRIDIUM DIFFICILE ANTIGEN (IN-HOUSE),14033025,CDM,306,RC,87324,HCPCS,Outpatient,,,96,96,,,,,,Other,Not Separately Reimbursable,88.26,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,88.26,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,70.08,73,,56.064,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.2,70,,53.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,19.19,,14.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48,50,,38.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,88.26,
A test of the stool to diagnose Clostridium difficile (C. diff) infection,14033026,CDM,306,RC,87070,HCPCS,Outpatient,,,107,107,,,,,,Other,Not Separately Reimbursable,88.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,88.28,82.5,,70.624,percent of total billed charges,Pays at 82.5% of total Billed charges,78.11,73,,62.488,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.9,70,,59.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.53,19.19,,16.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.5,50,,42.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.53,88.28,
CULTURE (THROAT),14033027,CDM,306,RC,87070,HCPCS,Outpatient,,,11.22,11.22,,,,,,Other,Not Separately Reimbursable,9.26,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.26,82.5,,7.408,percent of total billed charges,Pays at 82.5% of total Billed charges,8.19,73,,6.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.85,70,,6.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.15,19.19,,1.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.61,50,,4.488,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.15,9.26,
CULTURE (SPUTUM),14033028,CDM,306,RC,80195,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,9.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.9,82.5,,7.92,percent of total billed charges,Pays at 82.5% of total Billed charges,8.76,73,,7.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.4,70,,6.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,19.19,,1.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6,50,,4.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,9.9,
SIROLIMUS,14033029,CDM,301,RC,82131,HCPCS,Outpatient,,,105,105,,,,,,Other,Not Separately Reimbursable,86.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,86.63,82.5,,69.304,percent of total billed charges,Pays at 82.5% of total Billed charges,76.65,73,,61.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.5,70,,58.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,19.19,,16.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,50,,42,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,86.63,
CYSTATHIONINE SERUM,14033030,CDM,301,RC,86341,HCPCS,Outpatient,,,185,185,,,,,,Other,Not Separately Reimbursable,152.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,152.63,82.5,,122.104,percent of total billed charges,Pays at 82.5% of total Billed charges,135.05,73,,108.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,129.5,70,,103.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,19.19,,28.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.5,50,,74,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,152.63,
ANTIPANCREATIC ISLET CELLS,14033031,CDM,301,RC,87205,HCPCS,Outpatient,,,34.96,34.96,,,,,,Other,Not Separately Reimbursable,88.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,88.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,25.52,73,,20.416,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.47,70,,19.576,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.71,19.19,,5.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.48,50,,13.984,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.71,88.45,
A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,14033035,CDM,306,RC,86021,HCPCS,Outpatient,,,7.75,7.75,,,,,,Other,Not Separately Reimbursable,19.09,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,19.09,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,5.66,73,,4.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.43,70,,4.344,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.49,19.19,,1.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.88,50,,3.104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.49,19.09,
GRANULOCYTE ANTIBODIES,14033036,CDM,302,RC,87205,HCPCS,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
A lab test used to detect bacteria or fungi in a sample taken from the site of a suspected infection,14033038,CDM,306,RC,87075,HCPCS,Outpatient,,,79,79,,,,,,Other,Not Separately Reimbursable,19.09,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,19.09,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,57.67,73,,46.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.3,70,,44.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,19.19,,12.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.5,50,,31.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,57.67,
ANAEROBIC CULTURE,14033042,CDM,306,RC,87206,HCPCS,Outpatient,,,256,256,,,,,,Other,Not Separately Reimbursable,211.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,211.2,82.5,,168.96,percent of total billed charges,Pays at 82.5% of total Billed charges,186.88,73,,149.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.2,70,,143.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.13,19.19,,39.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128,50,,102.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.13,211.2,
FUNGAL STAIN,14033043,CDM,306,RC,87077,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,24,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,24,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,24.09,
"ORGANISM IDENTIFICATION, BACTERIA",14033044,CDM,306,RC,87184,HCPCS,Outpatient,,,68,68,,,,,,Other,Not Separately Reimbursable,56.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.1,82.5,,44.88,percent of total billed charges,Pays at 82.5% of total Billed charges,49.64,73,,39.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.6,70,,38.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,19.19,,10.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34,50,,27.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,56.1,
SENS ONLY SEND OUT,14033045,CDM,306,RC,87184,HCPCS,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,20.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,20.63,82.5,,16.504,percent of total billed charges,Pays at 82.5% of total Billed charges,18.25,73,,14.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,70,,14,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,19.19,,3.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,50,,10,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,20.63,
"CULTURE,AEROBIC (ANTHRAX)",14033046,CDM,306,RC,87077,HCPCS,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,20.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,20.63,82.5,,16.504,percent of total billed charges,Pays at 82.5% of total Billed charges,18.25,73,,14.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,70,,14,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,19.19,,3.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,50,,10,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,20.63,
"ID & SENS,SEND OUT",14033047,CDM,306,RC,84586,HCPCS,Outpatient,,,68,68,,,,,,Other,Not Separately Reimbursable,56.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.1,82.5,,44.88,percent of total billed charges,Pays at 82.5% of total Billed charges,49.64,73,,39.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.6,70,,38.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,19.19,,10.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34,50,,27.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,56.1,
VASOACTIVE INTESTINAL PEPTIDE,14033048,CDM,301,RC,87206,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
FUNGUS SMEAR,14033050,CDM,306,RC,84311,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
PORPHYRINS PLASMA,14033057,CDM,301,RC,87206,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
CULTURE/SMEAR (FUNGUS),14033068,CDM,306,RC,80299,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
ZONISAMIDE (ZONEGRAN),14033074,CDM,301,RC,80168,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
ZARONTIN (ETHOSUXIMIDE),14033075,CDM,301,RC,87116,HCPCS,Outpatient,,,69,69,,,,,,Other,Not Separately Reimbursable,56.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.93,82.5,,45.544,percent of total billed charges,Pays at 82.5% of total Billed charges,50.37,73,,40.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.3,70,,38.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.24,19.19,,10.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,50,,27.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.24,56.93,
CULTURE ACID FAST,14033076,CDM,306,RC,80299,HCPCS,Outpatient,,,23.1,23.1,,,,,,Other,Not Separately Reimbursable,48.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,48.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,16.86,73,,13.488,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.17,70,,12.936,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.43,19.19,,3.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.55,50,,9.24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.43,48.32,
PROZAC (FLUOXETINE),14033077,CDM,301,RC,86710,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
"INFLUENZA A&B Ab,QUANT.",14033078,CDM,302,RC,83918,HCPCS,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,47.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.03,82.5,,37.624,percent of total billed charges,Pays at 82.5% of total Billed charges,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,47.03,
ORGANIC ACID (URINE),14033079,CDM,301,RC,86747,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
"PARVOVIRUS B19, IgG/IgM",14033080,CDM,302,RC,84630,HCPCS,Outpatient,,,63,63,,,,,,Other,Not Separately Reimbursable,51.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,51.98,82.5,,41.584,percent of total billed charges,Pays at 82.5% of total Billed charges,45.99,73,,36.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.1,70,,35.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,19.19,,9.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,50,,25.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,51.98,
"ZINC LEVEL,SERUM",14033081,CDM,301,RC,84630,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
"ZINC LEVEL,WHOLE BLOOD",14033082,CDM,301,RC,87206,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,50.94,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,50.94,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,50.94,
ACID FAST SMEAR ONLY,14033084,CDM,306,RC,80195,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
"SIROLIMUS, WHOLE BLOOD",14033092,CDM,301,RC,36415,HCPCS,Outpatient,,,105,105,,,,,,Other,Not Separately Reimbursable,86.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,86.63,82.5,,69.304,percent of total billed charges,Pays at 82.5% of total Billed charges,76.65,73,,61.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.5,70,,58.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,19.19,,16.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,50,,42,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,86.63,
Collection of venous blood by venipuncture,14033093,CDM,300,RC,36415,HCPCS,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,9.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,9.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,18.25,73,,14.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,70,,14,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,19.19,,3.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,50,,10,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,18.25,
Collection of venous blood by venipuncture,14033095,CDM,300,RC,80053,HCPCS,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,9.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,9.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,18.25,73,,14.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,70,,14,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,19.19,,3.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,50,,10,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,18.25,
"Blood test, comprehensive group of blood chemicals",14033096,CDM,301,RC,80069,HCPCS,Outpatient,,,215,215,,,,,,Other,Not Separately Reimbursable,46.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,46.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,156.95,73,,125.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,150.5,70,,120.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.26,19.19,,33.008,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.5,50,,86,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.26,156.95,
Kidney function panel test,14033097,CDM,301,RC,88184,HCPCS,Outpatient,,,132,132,,,,,,Other,Not Separately Reimbursable,108.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,108.9,82.5,,87.12,percent of total billed charges,Pays at 82.5% of total Billed charges,96.36,73,,77.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.4,70,,73.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.33,19.19,,20.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66,50,,52.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.33,108.9,
HLA ANTIBODY SCREEN,14033106,CDM,302,RC,81291,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
MTHFR GENOTYPE - CUSTOM CHARGE,14033140,CDM,301,RC,87799,HCPCS,Outpatient,,,91.6,91.6,,,,,,Other,Not Separately Reimbursable,75.57,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,75.57,82.5,,60.456,percent of total billed charges,Pays at 82.5% of total Billed charges,66.87,73,,53.496,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.12,70,,51.296,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.58,19.19,,14.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.8,50,,36.64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.58,75.57,
BK (POLYOMAVIRUS) DNA ULTRAQUANT,14033150,CDM,301,RC,83993,HCPCS,Outpatient,,,229,229,,,,,,Other,Not Separately Reimbursable,188.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,188.93,82.5,,151.144,percent of total billed charges,Pays at 82.5% of total Billed charges,167.17,73,,133.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,160.3,70,,128.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.95,19.19,,35.16,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,114.5,50,,91.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.95,188.93,
CALPROTECTIN FECAL,14033160,CDM,302,RC,,,Outpatient,,,216,216,,,,,,Other,Not Separately Reimbursable,178.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,178.2,82.5,,142.56,percent of total billed charges,Pays at 82.5% of total Billed charges,157.68,73,,126.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.2,70,,120.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.45,19.19,,33.16,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108,50,,86.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.45,178.2,
ANABOLIC STEROID SCREEN URINE,14033200,CDM,301,RC,87802,HCPCS,Outpatient,,,121,121,,,,,,Other,Not Separately Reimbursable,99.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99.83,82.5,,79.864,percent of total billed charges,Pays at 82.5% of total Billed charges,88.33,73,,70.664,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.7,70,,67.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.22,19.19,,18.576,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.5,50,,48.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.22,99.83,
BETA HEMOLYTIC GROUP A STREP,14033416,CDM,306,RC,80329,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
ACETOMINOPHEN LEVEL (TYLENOL),14034001,CDM,301,RC,86480,HCPCS,Outpatient,,,306,306,,,,,,Other,Not Separately Reimbursable,124.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,124.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,223.38,73,,178.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.2,70,,171.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,19.19,,46.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153,50,,122.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,223.38,
QUANTIFERON-TB GOLD,14034010,CDM,302,RC,83605,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,75.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,75.9,82.5,,60.72,percent of total billed charges,Pays at 82.5% of total Billed charges,67.16,73,,53.728,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.4,70,,51.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,19.19,,14.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46,50,,36.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,75.9,
LACTIC ACID,14034011,CDM,301,RC,85540,HCPCS,Outpatient,,,112,112,,,,,,Other,Not Separately Reimbursable,92.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,92.4,82.5,,73.92,percent of total billed charges,Pays at 82.5% of total Billed charges,81.76,73,,65.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.4,70,,62.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,19.19,,17.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,50,,44.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,92.4,
LEUKOCYTE ALKALINE PHOSPH,14034012,CDM,305,RC,80170,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
GENTAMICIN LEVEL,14034052,CDM,301,RC,85048,HCPCS,Outpatient,,,286,286,,,,,,Other,Not Separately Reimbursable,235.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,235.95,82.5,,188.76,percent of total billed charges,Pays at 82.5% of total Billed charges,208.78,73,,167.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,200.2,70,,160.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.88,19.19,,43.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143,50,,114.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.88,235.95,
WBC,14034053,CDM,305,RC,81050,HCPCS,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,11.37,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,11.37,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,21.17,
TIMED SPEC VOL MEAS,14034054,CDM,307,RC,84439,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,13.42,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,13.42,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,14.6,
Blood test to evaluate thyroid function,14034055,CDM,301,RC,84702,HCPCS,Outpatient,,,127,127,,,,,,Other,Not Separately Reimbursable,40.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,40.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,92.71,73,,74.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.9,70,,71.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.37,19.19,,19.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.5,50,,50.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.37,92.71,
HCG QUAL (PREGNANCY TEST),14034058,CDM,301,RC,80164,HCPCS,Outpatient,,,204,204,,,,,,Other,Not Separately Reimbursable,67.28,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,67.28,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,148.92,73,,119.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,142.8,70,,114.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.15,19.19,,31.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102,50,,81.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.15,148.92,
DEPAKENE- (VALPROIC ACID),14034069,CDM,301,RC,85378,HCPCS,Outpatient,,,141,141,,,,,,Other,Not Separately Reimbursable,60.57,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,60.57,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,102.93,73,,82.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.7,70,,78.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,19.19,,21.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.5,50,,56.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,102.93,
D-DIMER FIBRIN DEGRADATION,14034070,CDM,305,RC,85378,HCPCS,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,31.88,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,31.88,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,82.49,73,,65.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.1,70,,63.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,19.19,,17.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.5,50,,45.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,82.49,
COAGULATION PROF(DIC),14034071,CDM,305,RC,86003,HCPCS,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,93.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,93.23,82.5,,74.584,percent of total billed charges,Pays at 82.5% of total Billed charges,82.49,73,,65.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.1,70,,63.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,19.19,,17.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.5,50,,45.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,93.23,
ALLERGEN INDIVIDUAL,14034072,CDM,302,RC,82627,HCPCS,Outpatient,,,4.76,4.76,,,,,,Other,Not Separately Reimbursable,3.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.93,82.5,,3.144,percent of total billed charges,Pays at 82.5% of total Billed charges,3.47,73,,2.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.33,70,,2.664,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.91,19.19,,0.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.38,50,,1.904,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.91,3.93,
Blood test to measure an enzyme in the blood,14034073,CDM,301,RC,86666,HCPCS,Outpatient,,,110.25,110.25,,,,,,Other,Not Separately Reimbursable,99.41,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,99.41,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,80.48,73,,64.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.18,70,,61.744,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.16,19.19,,16.928,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.13,50,,44.104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.16,99.41,
EHRLICHIOSIS ANTIBODY PANEL,14034100,CDM,302,RC,80178,HCPCS,Outpatient,,,67,67,,,,,,Other,Not Separately Reimbursable,55.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,55.28,82.5,,44.224,percent of total billed charges,Pays at 82.5% of total Billed charges,48.91,73,,39.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,70,,37.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,19.19,,10.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.5,50,,26.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,55.28,
LITHIUM,14034101,CDM,301,RC,83519,HCPCS,Outpatient,,,13.64,13.64,,,,,,Other,Not Separately Reimbursable,11.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.25,82.5,,9,percent of total billed charges,Pays at 82.5% of total Billed charges,9.96,73,,7.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.55,70,,7.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.62,19.19,,2.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.82,50,,5.456,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.62,11.25,
PTH RELATED PROTEIN,14034102,CDM,301,RC,86609,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,170.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,170.78,82.5,,136.624,percent of total billed charges,Pays at 82.5% of total Billed charges,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,170.78,
STREP.PNEUMO IGG AB,14034103,CDM,302,RC,86738,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,75.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,75.9,82.5,,60.72,percent of total billed charges,Pays at 82.5% of total Billed charges,67.16,73,,53.728,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.4,70,,51.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,19.19,,14.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46,50,,36.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,75.9,
MYCOPLASMA AB IGG,14034104,CDM,302,RC,87015,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
PNEUMOCYSTIS SMEAR,14034105,CDM,302,RC,87109,HCPCS,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
MYCOPLASMA PNEUMONIAE CULTURE,14034106,CDM,306,RC,86618,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
"LYME AB,IGM,IGG/CSF",14034107,CDM,302,RC,86609,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
ROCKY MTN SPOT IGM,14034108,CDM,302,RC,86609,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,75.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,75.9,82.5,,60.72,percent of total billed charges,Pays at 82.5% of total Billed charges,67.16,73,,53.728,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.4,70,,51.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,19.19,,14.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46,50,,36.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,75.9,
"ROCKY MOUNTAIN SPOT IGG, IGM",14034109,CDM,302,RC,85007,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,75.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,75.9,82.5,,60.72,percent of total billed charges,Pays at 82.5% of total Billed charges,67.16,73,,53.728,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.4,70,,51.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,19.19,,14.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46,50,,36.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,75.9,
Blood test to assess for infection,14034110,CDM,305,RC,80188,HCPCS,Outpatient,,,82,82,,,,,,Other,Not Separately Reimbursable,15.4,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,15.4,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,59.86,73,,47.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.4,70,,45.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,19.19,,12.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41,50,,32.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.4,59.86,
MYSOLINE,14034111,CDM,301,RC,86618,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
LYME DISEASE ANTIBODIES,14034112,CDM,302,RC,83050,HCPCS,Outpatient,,,36.34,36.34,,,,,,Other,Not Separately Reimbursable,29.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,29.98,82.5,,23.984,percent of total billed charges,Pays at 82.5% of total Billed charges,26.53,73,,21.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.44,70,,20.352,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.97,19.19,,5.576,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.17,50,,14.536,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.97,29.98,
METHEMOGLOBIN,14034113,CDM,301,RC,80299,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
MEXITIL LEVEL,14034114,CDM,301,RC,86738,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
MYCOPLASMA PNEUMONIAE,14034115,CDM,302,RC,80299,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
METHOTREXATE,14034117,CDM,301,RC,80299,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
METHOCARBOMOL (ROBAXIN) LEVEL,14034118,CDM,301,RC,80299,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
METHYLPHENIDATE (RITALIN),14034119,CDM,301,RC,83735,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
MAGNESIUM SERUM,14034121,CDM,301,RC,80200,HCPCS,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,29.96,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,29.96,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,73,
TOBRAMYCIN LEVEL,14034122,CDM,301,RC,83970,HCPCS,Outpatient,,,225,225,,,,,,Other,Not Separately Reimbursable,72.07,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,72.07,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,164.25,73,,131.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.5,70,,126,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,19.19,,34.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112.5,50,,90,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,164.25,
"PARATHYROID HORMONE, INTACT",14034123,CDM,301,RC,86753,HCPCS,Outpatient,,,63.29,63.29,,,,,,Other,Not Separately Reimbursable,52.21,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.21,82.5,,41.768,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,73,,36.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.3,70,,35.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.15,19.19,,9.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.65,50,,25.32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.15,52.21,
PSITTACOSIS TITER,14034124,CDM,302,RC,80184,HCPCS,Outpatient,,,124,124,,,,,,Other,Not Separately Reimbursable,102.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,102.3,82.5,,81.84,percent of total billed charges,Pays at 82.5% of total Billed charges,90.52,73,,72.416,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.8,70,,69.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,19.19,,19.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62,50,,49.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,102.3,
PHENOBARBITAL,14034125,CDM,301,RC,87265,HCPCS,Outpatient,,,170,170,,,,,,Other,Not Separately Reimbursable,51.22,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.22,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,124.1,73,,99.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,119,70,,95.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.62,19.19,,26.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85,50,,68,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.62,124.1,
BORDETELLA PERT SMEAR,14034127,CDM,306,RC,86615,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
BORDETELLA ANTIBODY,14034128,CDM,302,RC,83497,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
HYDROXYINDO ACID 5 HIAA,14034129,CDM,301,RC,,,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
VET CBC,14034130,CDM,305,RC,80048,HCPCS,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
Basic metabolic panel,14034132,CDM,301,RC,87801,HCPCS,Outpatient,,,148,148,,,,,,Other,Not Separately Reimbursable,36.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,36.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,108.04,73,,86.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.6,70,,82.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.4,19.19,,22.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74,50,,59.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.4,108.04,
BORDETELLA PERTUSSIS BY PCR,14034140,CDM,301,RC,86622,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,75.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,75.9,82.5,,60.72,percent of total billed charges,Pays at 82.5% of total Billed charges,67.16,73,,53.728,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.4,70,,51.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,19.19,,14.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46,50,,36.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,75.9,
BRUCELLA TITER,14034151,CDM,306,RC,86738,HCPCS,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,31.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,31.35,82.5,,25.08,percent of total billed charges,Pays at 82.5% of total Billed charges,27.74,73,,22.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.6,70,,21.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,19.19,,5.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,50,,15.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,31.35,
MYCOPLASMA ANTIBODIES (IGM & IGG),14034152,CDM,306,RC,82710,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
RANDOM FECAL FAT,14034153,CDM,301,RC,86382,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,43.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,43.73,82.5,,34.984,percent of total billed charges,Pays at 82.5% of total Billed charges,38.69,73,,30.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.1,70,,29.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,19.19,,8.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.5,50,,21.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,43.73,
RABIES ANITBODY TITER,14034154,CDM,302,RC,83970,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
"PTH, BIO-INTACT (N TERMINAL PARATHYROID)",14034155,CDM,301,RC,82310,HCPCS,Outpatient,,,262,262,,,,,,Other,Not Separately Reimbursable,216.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,216.15,82.5,,172.92,percent of total billed charges,Pays at 82.5% of total Billed charges,191.26,73,,153.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,183.4,70,,146.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.28,19.19,,40.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,131,50,,104.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.28,216.15,
"PTH, C TERMINAL, WITH CA ONLY",14034156,CDM,301,RC,86003,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
RAST F2 MILK,14034157,CDM,302,RC,85613,HCPCS,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,15.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,15.68,82.5,,12.544,percent of total billed charges,Pays at 82.5% of total Billed charges,13.87,73,,11.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.3,70,,10.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,19.19,,2.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.5,50,,7.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,15.68,
RUSSELL VIPER VENOM DILUT,14034159,CDM,305,RC,84244,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
RENIN LEVEL PLASMA,14034165,CDM,301,RC,82570,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
"CREATININE, RANDOM URINE",14034205,CDM,301,RC,82340,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
CALCIUM RANDOM URINE,14034207,CDM,301,RC,84300,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
"SODIUM, 24 HR URINE",14034208,CDM,301,RC,87425,HCPCS,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,47.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.03,82.5,,37.624,percent of total billed charges,Pays at 82.5% of total Billed charges,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,47.03,
ROTAVIRUS,14034209,CDM,306,RC,82575,HCPCS,Outpatient,,,169,169,,,,,,Other,Not Separately Reimbursable,139.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,139.43,82.5,,111.544,percent of total billed charges,Pays at 82.5% of total Billed charges,123.37,73,,98.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,118.3,70,,94.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.43,19.19,,25.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.5,50,,67.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.43,139.43,
CREATININE CLEARANCE,14034210,CDM,301,RC,83001,HCPCS,Outpatient,,,121,121,,,,,,Other,Not Separately Reimbursable,99.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99.83,82.5,,79.864,percent of total billed charges,Pays at 82.5% of total Billed charges,88.33,73,,70.664,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.7,70,,67.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.22,19.19,,18.576,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.5,50,,48.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.22,99.83,
FSH,14034211,CDM,301,RC,82570,HCPCS,Outpatient,,,84.55,84.55,,,,,,Other,Not Separately Reimbursable,69.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,69.75,82.5,,55.8,percent of total billed charges,Pays at 82.5% of total Billed charges,61.72,73,,49.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.19,70,,47.352,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.23,19.19,,12.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.28,50,,33.824,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.23,69.75,
Test to measure creatinine in the urine,14034212,CDM,301,RC,84165,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,23.12,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,23.12,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,37.23,
PROTEIN ELECT RANDOM URINE,14034213,CDM,301,RC,86301,HCPCS,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
CA 19-9,14034214,CDM,302,RC,82482,HCPCS,Outpatient,,,86,86,,,,,,Other,Not Separately Reimbursable,70.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.95,82.5,,56.76,percent of total billed charges,Pays at 82.5% of total Billed charges,62.78,73,,50.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.2,70,,48.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,19.19,,13.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43,50,,34.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,70.95,
CHOLINESTERASE; RBC,14034215,CDM,301,RC,86300,HCPCS,Outpatient,,,69,69,,,,,,Other,Not Separately Reimbursable,56.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.93,82.5,,45.544,percent of total billed charges,Pays at 82.5% of total Billed charges,50.37,73,,40.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.3,70,,38.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.24,19.19,,10.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,50,,27.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.24,56.93,
CA 27-29,14034216,CDM,302,RC,82480,HCPCS,Outpatient,,,86,86,,,,,,Other,Not Separately Reimbursable,70.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.95,82.5,,56.76,percent of total billed charges,Pays at 82.5% of total Billed charges,62.78,73,,50.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.2,70,,48.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,19.19,,13.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43,50,,34.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,70.95,
"CHOLINESTERASE,SERUM",14034217,CDM,301,RC,83500,HCPCS,Outpatient,,,83,83,,,,,,Other,Not Separately Reimbursable,68.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,68.48,82.5,,54.784,percent of total billed charges,Pays at 82.5% of total Billed charges,60.59,73,,48.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.1,70,,46.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.93,19.19,,12.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.5,50,,33.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.93,68.48,
HYDROXYPROLINE 24 HR URINE,14034218,CDM,301,RC,85549,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,62.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,62.7,82.5,,50.16,percent of total billed charges,Pays at 82.5% of total Billed charges,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,62.7,
LYSOZYME,14034230,CDM,301,RC,82945,HCPCS,Outpatient,,,79,79,,,,,,Other,Not Separately Reimbursable,65.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,65.18,82.5,,52.144,percent of total billed charges,Pays at 82.5% of total Billed charges,57.67,73,,46.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.3,70,,44.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,19.19,,12.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.5,50,,31.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,65.18,
GLUCOSE URINE QUANTITATIVE,14034235,CDM,301,RC,82340,HCPCS,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
CALCIUM/CREATININE RANDOM URINE,14034238,CDM,301,RC,86300,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,27,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,27,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,51.1,
CA 15-3,14034249,CDM,302,RC,82378,HCPCS,Outpatient,,,86,86,,,,,,Other,Not Separately Reimbursable,70.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.95,82.5,,56.76,percent of total billed charges,Pays at 82.5% of total Billed charges,62.78,73,,50.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.2,70,,48.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,19.19,,13.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43,50,,34.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,70.95,
CEA (CARCINOEMBRYONIC ANTIGEN),14034251,CDM,301,RC,82746,HCPCS,Outpatient,,,31.68,31.68,,,,,,Other,Not Separately Reimbursable,26.14,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,26.14,82.5,,20.912,percent of total billed charges,Pays at 82.5% of total Billed charges,23.13,73,,18.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.18,70,,17.744,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.08,19.19,,4.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.84,50,,12.672,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.08,26.14,
FOLATE,14034252,CDM,301,RC,80158,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,65.74,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.74,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,87.6,
CYCLOSPORINE,14034253,CDM,301,RC,80158,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,47.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.85,82.5,,38.28,percent of total billed charges,Pays at 82.5% of total Billed charges,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,47.85,
WELLBUTRIN(BUPROPION) LEVEL,14034254,CDM,301,RC,82747,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,47.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.85,82.5,,38.28,percent of total billed charges,Pays at 82.5% of total Billed charges,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,47.85,
FOLATE RBC,14034255,CDM,301,RC,86000,HCPCS,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,20.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,20.63,82.5,,16.504,percent of total billed charges,Pays at 82.5% of total Billed charges,18.25,73,,14.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,70,,14,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,19.19,,3.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,50,,10,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,20.63,
FEBRILE AGGLUTININS,14034256,CDM,302,RC,82728,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
Test to determine level of iron in the blood,14034257,CDM,301,RC,85384,HCPCS,Outpatient,,,154,154,,,,,,Other,Not Separately Reimbursable,60.89,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,60.89,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,112.42,73,,89.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.8,70,,86.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.55,19.19,,23.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,50,,61.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.55,112.42,
FIBRINOGEN,14034258,CDM,305,RC,84430,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
THIOCYANATE,14034261,CDM,301,RC,82955,HCPCS,Outpatient,,,49,49,,,,,,Other,Not Separately Reimbursable,40.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,40.43,82.5,,32.344,percent of total billed charges,Pays at 82.5% of total Billed charges,35.77,73,,28.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.3,70,,27.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,19.19,,7.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,50,,19.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,40.43,
FIBRINOGEN ACTIVITY,14034262,CDM,305,RC,P9022,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,43.34,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,43.34,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,54.75,
WASHED RED BLOOD CELLS UNIT,14034522,CDM,380,RC,84255,HCPCS,Outpatient,,,550,550,,,,,,Other,Not Separately Reimbursable,359.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,359.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,401.5,73,,321.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,385,70,,308,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.55,19.19,,84.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,275,50,,220,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.55,401.5,
SELENIUM LEVEL,14034535,CDM,301,RC,P9021,HCPCS,Outpatient,,,256,256,,,,,,Other,Not Separately Reimbursable,211.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,211.2,82.5,,168.96,percent of total billed charges,Pays at 82.5% of total Billed charges,186.88,73,,149.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.2,70,,143.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.13,19.19,,39.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128,50,,102.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.13,211.2,
RED BLOOD CELLS UNIT,14034540,CDM,381,RC,82530,HCPCS,Outpatient,,,299,299,,,,,,Other,Not Separately Reimbursable,246.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,246.68,82.5,,197.344,percent of total billed charges,Pays at 82.5% of total Billed charges,218.27,73,,174.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,209.3,70,,167.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.38,19.19,,45.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.5,50,,119.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.38,246.68,
"CORTISOL, 24 HR URINE",14036110,CDM,301,RC,83491,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
HYDROXYCORTICO,14036111,CDM,301,RC,82530,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
CORTISOL FREE URINE,14036112,CDM,301,RC,83051,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
FREE HEMOGLOBIN,14036113,CDM,301,RC,86255,HCPCS,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,25.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,25.58,82.5,,20.464,percent of total billed charges,Pays at 82.5% of total Billed charges,22.63,73,,18.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.7,70,,17.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,19.19,,4.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.5,50,,12.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,25.58,
MYASTHENIA GRAVIS EVALUATION,14036114,CDM,302,RC,83586,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
17-KETOSTEROIDS 24 HOUR URINE,14036115,CDM,301,RC,83735,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
MAGNESIUM RBC,14036116,CDM,301,RC,80299,HCPCS,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
DARVOCET (PROPOXYPHENE),14036120,CDM,301,RC,80299,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
LORTAB/HYDROCODONE,14036121,CDM,301,RC,80342,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
"THORAZINE(CHLORPROMAZINE),SERUM",14036122,CDM,301,RC,83735,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,54.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,54.45,82.5,,43.56,percent of total billed charges,Pays at 82.5% of total Billed charges,48.18,73,,38.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.2,70,,36.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,19.19,,10.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33,50,,26.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,54.45,
MAGNESIUM IONIZED,14036123,CDM,301,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
TRILEPTAL MED,14036124,CDM,301,RC,84255,HCPCS,Outpatient,,,19.81,19.81,,,,,,Other,Not Separately Reimbursable,16.34,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.34,82.5,,13.072,percent of total billed charges,Pays at 82.5% of total Billed charges,14.46,73,,11.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.87,70,,11.096,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.8,19.19,,3.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.91,50,,7.928,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.8,16.34,
SELENIUM 24 HR URINE,14036200,CDM,301,RC,84630,HCPCS,Outpatient,,,256,256,,,,,,Other,Not Separately Reimbursable,211.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,211.2,82.5,,168.96,percent of total billed charges,Pays at 82.5% of total Billed charges,186.88,73,,149.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.2,70,,143.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.13,19.19,,39.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128,50,,102.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.13,211.2,
ZINC 24 HR URINE,14036220,CDM,301,RC,83885,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
NICKEL RANDOM URINE,14036230,CDM,301,RC,82300,HCPCS,Outpatient,,,123,123,,,,,,Other,Not Separately Reimbursable,101.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,101.48,82.5,,81.184,percent of total billed charges,Pays at 82.5% of total Billed charges,89.79,73,,71.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.1,70,,68.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.6,19.19,,18.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.5,50,,49.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.6,101.48,
CADMIUM URINE RANDOM,14036250,CDM,301,RC,36430,HCPCS,Outpatient,,,102,102,,,,,,Other,Not Separately Reimbursable,84.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,84.15,82.5,,67.32,percent of total billed charges,Pays at 82.5% of total Billed charges,74.46,73,,59.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.4,70,,57.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,19.19,,15.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51,50,,40.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,84.15,
BLOOD TRANSFUSION,14041013,CDM,391,RC,83633,HCPCS,Outpatient,,,643,643,,,,,,Other,Not Separately Reimbursable,530.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,530.48,82.5,,424.384,percent of total billed charges,Pays at 82.5% of total Billed charges,469.39,73,,375.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,450.1,70,,360.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,123.39,19.19,,98.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,321.5,50,,257.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,123.39,530.48,
LACTOSE TOLERANCE TEST URINE,14043000,CDM,301,RC,82951,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,24.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,24.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,46.72,
Test to predict likelihood of gestational diabetes,14043001,CDM,301,RC,85025,HCPCS,Outpatient,,,34,34,,,,,,Other,Not Separately Reimbursable,50.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,50.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,24.82,73,,19.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,70,,19.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,19.19,,5.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17,50,,13.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,50.43,
"Complete blood cell count, with differential white blood cells, automated",14050001,CDM,305,RC,80306,HCPCS,Outpatient,,,135,135,,,,,,Other,Not Separately Reimbursable,34.78,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,34.78,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,98.55,73,,78.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.5,70,,75.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.91,19.19,,20.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.5,50,,54,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.91,98.55,
DRUG SCREEN-UR QUALITATIVE,14080306,CDM,301,RC,81161,HCPCS,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,61.68,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,61.68,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,63.51,73,,50.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.9,70,,48.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,19.19,,13.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.5,50,,34.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,63.51,
DMD DELETION ANALYS/ DUPL ANALY IF PERF,14081161,CDM,301,RC,81200,HCPCS,Outpatient,,,1120,1120,,,,,,Other,Not Separately Reimbursable,924,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,924,82.5,,739.2,percent of total billed charges,Pays at 82.5% of total Billed charges,817.6,73,,654.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,784,70,,627.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.93,19.19,,171.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,560,50,,448,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.93,924,
ASPA GENE ANALYSIS,14081200,CDM,301,RC,81205,HCPCS,Outpatient,,,721.2,721.2,,,,,,Other,Not Separately Reimbursable,594.99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,594.99,82.5,,475.992,percent of total billed charges,Pays at 82.5% of total Billed charges,526.48,73,,421.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,504.84,70,,403.872,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,138.4,19.19,,110.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,360.6,50,,288.48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,138.4,594.99,
BCKDHB GENE ANALYSIS,14081205,CDM,301,RC,81209,HCPCS,Outpatient,,,806.96,806.96,,,,,,Other,Not Separately Reimbursable,665.74,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,665.74,82.5,,532.592,percent of total billed charges,Pays at 82.5% of total Billed charges,589.08,73,,471.264,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,564.87,70,,451.896,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154.86,19.19,,123.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,403.48,50,,322.784,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154.86,665.74,
BLM GENE ANALYSIS,14081209,CDM,301,RC,81220,HCPCS,Outpatient,,,466.08,466.08,,,,,,Other,Not Separately Reimbursable,384.52,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,384.52,82.5,,307.616,percent of total billed charges,Pays at 82.5% of total Billed charges,340.24,73,,272.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,326.26,70,,261.008,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.44,19.19,,71.552,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,233.04,50,,186.432,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.44,384.52,
CFTR GENE ANALYSIS,14081220,CDM,301,RC,81242,HCPCS,Outpatient,,,4373.2,4373.2,,,,,,Other,Not Separately Reimbursable,3607.89,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3607.89,82.5,,2886.312,percent of total billed charges,Pays at 82.5% of total Billed charges,3192.44,73,,2553.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3061.24,70,,2448.992,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,839.22,19.19,,671.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2186.6,50,,1749.28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,839.22,3607.89,
FANCC GENE ANALYSIS,14081242,CDM,301,RC,81243,HCPCS,Outpatient,,,583.36,583.36,,,,,,Other,Not Separately Reimbursable,481.27,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,481.27,82.5,,385.016,percent of total billed charges,Pays at 82.5% of total Billed charges,425.85,73,,340.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,408.35,70,,326.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.95,19.19,,89.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,291.68,50,,233.344,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.95,481.27,
FEMALE ONLY - FMR1 GENE ANALYSIS,14081243,CDM,301,RC,81250,HCPCS,Outpatient,,,504,504,,,,,,Other,Not Separately Reimbursable,415.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,415.8,82.5,,332.64,percent of total billed charges,Pays at 82.5% of total Billed charges,367.92,73,,294.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,352.8,70,,282.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.72,19.19,,77.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252,50,,201.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.72,415.8,
G6PC GENE ANALYSIS,14081250,CDM,301,RC,81251,HCPCS,Outpatient,,,573.2,573.2,,,,,,Other,Not Separately Reimbursable,472.89,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,472.89,82.5,,378.312,percent of total billed charges,Pays at 82.5% of total Billed charges,418.44,73,,334.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,401.24,70,,320.992,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110,19.19,,88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,286.6,50,,229.28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110,472.89,
GBA GENE ANALYSIS,14081251,CDM,301,RC,81252,HCPCS,Outpatient,,,816.16,816.16,,,,,,Other,Not Separately Reimbursable,673.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,673.33,82.5,,538.664,percent of total billed charges,Pays at 82.5% of total Billed charges,595.8,73,,476.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,571.31,70,,457.048,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,156.62,19.19,,125.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,408.08,50,,326.464,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,156.62,673.33,
GJB2 GENE ANALYSIS,14081252,CDM,301,RC,81254,HCPCS,Outpatient,,,1671.6,1671.6,,,,,,Other,Not Separately Reimbursable,1379.07,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1379.07,82.5,,1103.256,percent of total billed charges,Pays at 82.5% of total Billed charges,1220.27,73,,976.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1170.12,70,,936.096,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,320.78,19.19,,256.624,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,835.8,50,,668.64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,320.78,1379.07,
GJ86 GENE ANALYSIS,14081254,CDM,301,RC,81255,HCPCS,Outpatient,,,711.28,711.28,,,,,,Other,Not Separately Reimbursable,586.81,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,586.81,82.5,,469.448,percent of total billed charges,Pays at 82.5% of total Billed charges,519.23,73,,415.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,497.9,70,,398.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,136.49,19.19,,109.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,355.64,50,,284.512,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,136.49,586.81,
HEXA GENE ANALYSIS,14081255,CDM,301,RC,81260,HCPCS,Outpatient,,,681.2,681.2,,,,,,Other,Not Separately Reimbursable,561.99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,561.99,82.5,,449.592,percent of total billed charges,Pays at 82.5% of total Billed charges,497.28,73,,397.824,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,476.84,70,,381.472,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,130.72,19.19,,104.576,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,340.6,50,,272.48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,130.72,561.99,
IKBKAP GENE ANALYSIS,14081260,CDM,301,RC,81290,HCPCS,Outpatient,,,626.64,626.64,,,,,,Other,Not Separately Reimbursable,516.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,516.98,82.5,,413.584,percent of total billed charges,Pays at 82.5% of total Billed charges,457.45,73,,365.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,438.65,70,,350.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,120.25,19.19,,96.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,313.32,50,,250.656,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,120.25,516.98,
MCOLN1 GENE ANALYSIS,14081290,CDM,301,RC,81330,HCPCS,Outpatient,,,571.2,571.2,,,,,,Other,Not Separately Reimbursable,471.24,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,471.24,82.5,,376.992,percent of total billed charges,Pays at 82.5% of total Billed charges,416.98,73,,333.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,399.84,70,,319.872,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.61,19.19,,87.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,285.6,50,,228.48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.61,471.24,
SMPD1 GENE ANALYSIS,14081330,CDM,301,RC,81332,HCPCS,Outpatient,,,684.08,684.08,,,,,,Other,Not Separately Reimbursable,564.37,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,564.37,82.5,,451.496,percent of total billed charges,Pays at 82.5% of total Billed charges,499.38,73,,399.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,478.86,70,,383.088,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,131.27,19.19,,105.016,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,342.04,50,,273.632,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,131.27,564.37,
SERPINA1 GENE ANALYSIS,14081332,CDM,301,RC,80053,HCPCS,Outpatient,,,475.2,475.2,,,,,,Other,Not Separately Reimbursable,392.04,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,392.04,82.5,,313.632,percent of total billed charges,Pays at 82.5% of total Billed charges,346.9,73,,277.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,332.64,70,,266.112,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.19,19.19,,72.952,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,237.6,50,,190.08,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.19,392.04,
"Blood test, comprehensive group of blood chemicals",14082335,CDM,301,RC,82043,HCPCS,Outpatient,,,179.68,179.68,,,,,,Other,Not Separately Reimbursable,46.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,46.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,131.17,73,,104.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125.78,70,,100.624,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.48,19.19,,27.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.84,50,,71.872,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.48,131.17,
MICROALBUMIN RANDOM,14082403,CDM,301,RC,87086,HCPCS,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,25.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,25.58,82.5,,20.464,percent of total billed charges,Pays at 82.5% of total Billed charges,22.63,73,,18.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.7,70,,17.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,19.19,,4.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.5,50,,12.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,25.58,
CULTURE (URINE) CATH,14087086,CDM,306,RC,87493,HCPCS,Outpatient,,,7.75,7.75,,,,,,Other,Not Separately Reimbursable,6.39,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6.39,82.5,,5.112,percent of total billed charges,Pays at 82.5% of total Billed charges,5.66,73,,4.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.43,70,,4.344,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.49,19.19,,1.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.88,50,,3.104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.49,6.39,
C DIFF BY PCR,14087493,CDM,300,RC,87651,HCPCS,Outpatient,,,142,142,,,,,,Other,Not Separately Reimbursable,117.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,117.15,82.5,,93.72,percent of total billed charges,Pays at 82.5% of total Billed charges,103.66,73,,82.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.4,70,,79.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,19.19,,21.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,50,,56.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,117.15,
GROUP A STREP BY DNA,14087651,CDM,300,RC,82951,HCPCS,Outpatient,,,142,142,,,,,,Other,Not Separately Reimbursable,117.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,117.15,82.5,,93.72,percent of total billed charges,Pays at 82.5% of total Billed charges,103.66,73,,82.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.4,70,,79.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,19.19,,21.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,50,,56.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,117.15,
5 HR GTT,14100843,CDM,301,RC,80299,HCPCS,Outpatient,,,102,102,,,,,,Other,Not Separately Reimbursable,84.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,84.15,82.5,,67.32,percent of total billed charges,Pays at 82.5% of total Billed charges,74.46,73,,59.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.4,70,,57.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,19.19,,15.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51,50,,40.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,84.15,
GABAPENTIN (NEURONTIN),14110831,CDM,301,RC,83519,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
THYROID RELEASI HORM,14110832,CDM,301,RC,86663,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,170.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,170.78,82.5,,136.624,percent of total billed charges,Pays at 82.5% of total Billed charges,151.11,73,,120.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.9,70,,115.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,19.19,,31.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.5,50,,82.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.72,170.78,
EPSTEIN BARR VIRUS ANTIBOD,14110833,CDM,302,RC,86735,HCPCS,Outpatient,,,38.4,38.4,,,,,,Other,Not Separately Reimbursable,58.65,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,58.65,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,28.03,73,,22.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.88,70,,21.504,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.37,19.19,,5.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.2,50,,15.36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.37,58.65,
MUMPS ANTIBODY,14110834,CDM,302,RC,80200,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
TOBRAMYCIN PEAK,14110836,CDM,301,RC,80200,HCPCS,Outpatient,,,225,225,,,,,,Other,Not Separately Reimbursable,72.07,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,72.07,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,164.25,73,,131.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.5,70,,126,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,19.19,,34.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112.5,50,,90,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,164.25,
TOBRAMYCIN TROUGH,14110837,CDM,301,RC,80202,HCPCS,Outpatient,,,225,225,,,,,,Other,Not Separately Reimbursable,72.07,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,72.07,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,164.25,73,,131.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.5,70,,126,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,19.19,,34.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112.5,50,,90,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,164.25,
VANCOMYCIN TROUGH,14110838,CDM,301,RC,80202,HCPCS,Outpatient,,,212,212,,,,,,Other,Not Separately Reimbursable,60.57,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,60.57,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,154.76,73,,123.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.4,70,,118.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.68,19.19,,32.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,106,50,,84.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.68,154.76,
VANCOMYCIN PEAK,14110839,CDM,301,RC,80170,HCPCS,Outpatient,,,212,212,,,,,,Other,Not Separately Reimbursable,60.57,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,60.57,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,154.76,73,,123.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.4,70,,118.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.68,19.19,,32.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,106,50,,84.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.68,154.76,
GENTAMICIN TROUGH,14110840,CDM,301,RC,80170,HCPCS,Outpatient,,,286,286,,,,,,Other,Not Separately Reimbursable,235.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,235.95,82.5,,188.76,percent of total billed charges,Pays at 82.5% of total Billed charges,208.78,73,,167.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,200.2,70,,160.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.88,19.19,,43.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143,50,,114.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.88,235.95,
GENTAMICIN PEAK,14110841,CDM,301,RC,82951,HCPCS,Outpatient,,,286,286,,,,,,Other,Not Separately Reimbursable,235.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,235.95,82.5,,188.76,percent of total billed charges,Pays at 82.5% of total Billed charges,208.78,73,,167.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,200.2,70,,160.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.88,19.19,,43.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143,50,,114.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.88,235.95,
4 HR GTT,14110842,CDM,301,RC,86720,HCPCS,Outpatient,,,102,102,,,,,,Other,Not Separately Reimbursable,84.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,84.15,82.5,,67.32,percent of total billed charges,Pays at 82.5% of total Billed charges,74.46,73,,59.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.4,70,,57.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,19.19,,15.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51,50,,40.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,84.15,
LEPTOSPIRA ANTIBODY,14110843,CDM,302,RC,82951,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
6 HR GTT,14110844,CDM,301,RC,89050,HCPCS,Outpatient,,,102,102,,,,,,Other,Not Separately Reimbursable,84.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,84.15,82.5,,67.32,percent of total billed charges,Pays at 82.5% of total Billed charges,74.46,73,,59.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.4,70,,57.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,19.19,,15.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51,50,,40.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,84.15,
CSF CELL COUNT,14110845,CDM,300,RC,86920,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
CROSSMATCH-ADDITIONAL,14110846,CDM,302,RC,89060,HCPCS,Outpatient,,,205,205,,,,,,Other,Not Separately Reimbursable,169.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,169.13,82.5,,135.304,percent of total billed charges,Pays at 82.5% of total Billed charges,149.65,73,,119.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.5,70,,114.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,19.19,,31.472,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.5,50,,82,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,169.13,
CRYSTAL ANALYSIS,14110848,CDM,300,RC,80157,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,31.97,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,31.97,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,42.34,
CARBAMAZEPINE TOTAL,14110850,CDM,301,RC,80185,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
PHENYTOIN,14110852,CDM,301,RC,80185,HCPCS,Outpatient,,,215,215,,,,,,Other,Not Separately Reimbursable,59.28,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,59.28,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,156.95,73,,125.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,150.5,70,,120.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.26,19.19,,33.008,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.5,50,,86,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.26,156.95,
"PHENYTOIN, FREE & TOTAL",14110853,CDM,301,RC,80164,HCPCS,Outpatient,,,215,215,,,,,,Other,Not Separately Reimbursable,177.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,177.38,82.5,,141.904,percent of total billed charges,Pays at 82.5% of total Billed charges,156.95,73,,125.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,150.5,70,,120.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.26,19.19,,33.008,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.5,50,,86,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.26,177.38,
VALPROIC ACID,14110854,CDM,301,RC,86682,HCPCS,Outpatient,,,141,141,,,,,,Other,Not Separately Reimbursable,60.57,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,60.57,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,102.93,73,,82.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.7,70,,78.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,19.19,,21.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.5,50,,56.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,102.93,
STRONGYLOIDES ANTIBODY IGG,14110856,CDM,301,RC,87798,HCPCS,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,58.15,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,58.15,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,65.7,
ENTEROVIRUS-CSF,14110862,CDM,306,RC,86900,HCPCS,Outpatient,,,317,317,,,,,,Other,Not Separately Reimbursable,261.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,261.53,82.5,,209.224,percent of total billed charges,Pays at 82.5% of total Billed charges,231.41,73,,185.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,221.9,70,,177.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.83,19.19,,48.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,158.5,50,,126.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.83,261.53,
ABO GROUP,14141050,CDM,302,RC,86901,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,13.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,13.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,25.55,73,,20.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,70,,19.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,19.19,,5.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,50,,14,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,25.55,
RH (D) TYPING,14141150,CDM,302,RC,86850,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,28.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.88,82.5,,23.104,percent of total billed charges,Pays at 82.5% of total Billed charges,25.55,73,,20.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,70,,19.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,19.19,,5.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,50,,14,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,28.88,
Blood test to screen for antibodies that could harm red blood cells,14141350,CDM,302,RC,86880,HCPCS,Outpatient,,,109,109,,,,,,Other,Not Separately Reimbursable,89.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,89.93,82.5,,71.944,percent of total billed charges,Pays at 82.5% of total Billed charges,79.57,73,,63.656,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.3,70,,61.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.92,19.19,,16.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.5,50,,43.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.92,89.93,
COOMBS DIRECT,14141550,CDM,302,RC,86920,HCPCS,Outpatient,,,62,62,,,,,,Other,Not Separately Reimbursable,24,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,24,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,45.26,73,,36.208,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.4,70,,34.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,19.19,,9.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31,50,,24.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,45.26,
IMM SPIN CROSSMATCH,14141625,CDM,302,RC,86922,HCPCS,Outpatient,,,205,205,,,,,,Other,Not Separately Reimbursable,169.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,169.13,82.5,,135.304,percent of total billed charges,Pays at 82.5% of total Billed charges,149.65,73,,119.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.5,70,,114.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,19.19,,31.472,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.5,50,,82,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,169.13,
IGG CROSSMATCH,14141660,CDM,390,RC,86902,HCPCS,Outpatient,,,116,116,,,,,,Other,Not Separately Reimbursable,95.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,95.7,82.5,,76.56,percent of total billed charges,Pays at 82.5% of total Billed charges,84.68,73,,67.744,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.2,70,,64.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.26,19.19,,17.808,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58,50,,46.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.26,95.7,
SP ANG TYPING (CHG),14141675,CDM,302,RC,P9021,HCPCS,Outpatient,,,44,44,,,,,,Other,Not Separately Reimbursable,26.37,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,26.37,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,32.12,73,,25.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.8,70,,24.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,19.19,,6.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22,50,,17.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,32.12,
PACKED RED BLOOD CELLS UNIT,14141685,CDM,381,RC,86927,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
FFP THAW CHG,14141750,CDM,390,RC,P9017,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
FRESH FROZEN PLASMA (PRODUCT) CHG,14141775,CDM,383,RC,86965,HCPCS,Outpatient,,,134,134,,,,,,Other,Not Separately Reimbursable,141.75,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,141.75,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,97.82,73,,78.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.8,70,,75.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.71,19.19,,20.568,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67,50,,53.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.71,141.75,
PLATLET POOLING CHG,14141810,CDM,302,RC,P9019,HCPCS,Outpatient,,,148,148,,,,,,Other,Not Separately Reimbursable,122.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.1,82.5,,97.68,percent of total billed charges,Pays at 82.5% of total Billed charges,108.04,73,,86.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.6,70,,82.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.4,19.19,,22.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74,50,,59.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.4,122.1,
"PLATELETS, EACH UNIT CHG",14141820,CDM,384,RC,P9035,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,138.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,138.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,138.6,
"PLATELETS, APHERESIS CHG",14141885,CDM,384,RC,84133,HCPCS,Outpatient,,,1271,1271,,,,,,Other,Not Separately Reimbursable,1048.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1048.58,82.5,,838.864,percent of total billed charges,Pays at 82.5% of total Billed charges,927.83,73,,742.264,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,889.7,70,,711.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,243.9,19.19,,195.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,635.5,50,,508.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,243.9,1048.58,
POTASSIUM URINE 24 HOUR,14160000,CDM,301,RC,82436,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,19.22,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,19.22,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,46.72,
CHLORIDE URINE 24 HOUR,14160001,CDM,301,RC,84300,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,14.18,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,14.18,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,51.83,
SODIUM URINE,14160014,CDM,301,RC,84133,HCPCS,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,21.74,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,21.74,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,41.61,
POTASSIUM URINE,14160015,CDM,301,RC,82436,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,19.22,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,19.22,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,46.72,
CHLORIDE URINE,14160016,CDM,301,RC,P9017,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,14.18,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,14.18,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,51.83,
"FFP [FRESH FROZEN PLASMA], EACH UNIT",14160017,CDM,383,RC,P9019,HCPCS,Outpatient,,,184,184,,,,,,Other,Not Separately Reimbursable,141.75,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,141.75,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,134.32,73,,107.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.8,70,,103.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,19.19,,28.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92,50,,73.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,141.75,
"PLATELETS, EACH UNIT",14160018,CDM,384,RC,82951,HCPCS,Outpatient,,,153,153,,,,,,Other,Not Separately Reimbursable,138.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,138.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,111.69,73,,89.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.1,70,,85.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.36,19.19,,23.488,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.5,50,,61.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.36,138.6,
Test to predict likelihood of gestational diabetes,14160019,CDM,301,RC,81015,HCPCS,Outpatient,,,102,102,,,,,,Other,Not Separately Reimbursable,50.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,50.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,74.46,73,,59.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.4,70,,57.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,19.19,,15.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51,50,,40.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,74.46,
URINE MICROSCOPIC,14160020,CDM,307,RC,80306,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,12.54,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,12.54,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,24.09,
DRUG SC/CHAIN OF CUSTODY,14180306,CDM,301,RC,87493,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
C DIFF QUIK CHECK,14187493,CDM,300,RC,88108,HCPCS,Outpatient,,,142,142,,,,,,Other,Not Separately Reimbursable,117.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,117.15,82.5,,93.72,percent of total billed charges,Pays at 82.5% of total Billed charges,103.66,73,,82.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.4,70,,79.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,19.19,,21.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,50,,56.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,117.15,
CYTOLOGY; CONCENTRATION,14788108,CDM,311,RC,88112,HCPCS,Outpatient,,,26.38,26.38,,,,,,Other,Not Separately Reimbursable,21.76,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,21.76,82.5,,17.408,percent of total billed charges,Pays at 82.5% of total Billed charges,19.26,73,,15.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.47,70,,14.776,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.06,19.19,,4.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.19,50,,10.552,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.06,21.76,
CYTOLOGY W/ SELECTIVE CELLULAR ENHANCEME,14788112,CDM,311,RC,88173,HCPCS,Outpatient,,,24.76,24.76,,,,,,Other,Not Separately Reimbursable,20.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,20.43,82.5,,16.344,percent of total billed charges,Pays at 82.5% of total Billed charges,18.07,73,,14.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.33,70,,13.864,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.75,19.19,,3.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.38,50,,9.904,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.75,20.43,
CYTOPATHOLOGY INTERPRETATION & REPORT,14788173,CDM,311,RC,88300,HCPCS,Outpatient,,,37.98,37.98,,,,,,Other,Not Separately Reimbursable,31.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,31.33,82.5,,25.064,percent of total billed charges,Pays at 82.5% of total Billed charges,27.73,73,,22.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.59,70,,21.272,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,19.19,,5.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.99,50,,15.192,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,31.33,
"TISSUE EXAM, LEVEL 1",14788300,CDM,310,RC,88302,HCPCS,Outpatient,,,12.79,12.79,,,,,,Other,Not Separately Reimbursable,10.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.55,82.5,,8.44,percent of total billed charges,Pays at 82.5% of total Billed charges,9.34,73,,7.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.95,70,,7.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.45,19.19,,1.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.4,50,,5.12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.45,10.55,
"MICROSCOPIC ANALYSIS, LEVEL 2",14788302,CDM,310,RC,88304,HCPCS,Outpatient,,,26.38,26.38,,,,,,Other,Not Separately Reimbursable,21.76,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,21.76,82.5,,17.408,percent of total billed charges,Pays at 82.5% of total Billed charges,19.26,73,,15.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.47,70,,14.776,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.06,19.19,,4.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.19,50,,10.552,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.06,21.76,
"MICROSCOPIC ANALYSIS, LEVEL 3",14788304,CDM,310,RC,88305,HCPCS,Outpatient,,,27.29,27.29,,,,,,Other,Not Separately Reimbursable,22.51,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,22.51,82.5,,18.008,percent of total billed charges,Pays at 82.5% of total Billed charges,19.92,73,,15.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.1,70,,15.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.24,19.19,,4.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.65,50,,10.92,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.24,22.51,
"MICROSCOPIC ANALYSIS, LEVEL 4",14788305,CDM,310,RC,88307,HCPCS,Outpatient,,,37.26,37.26,,,,,,Other,Not Separately Reimbursable,30.74,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,30.74,82.5,,24.592,percent of total billed charges,Pays at 82.5% of total Billed charges,27.2,73,,21.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.08,70,,20.864,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.15,19.19,,5.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.63,50,,14.904,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.15,30.74,
"MICROSCOPIC ANALYSIS, LEVEL 5",14788307,CDM,310,RC,88309,HCPCS,Outpatient,,,82.92,82.92,,,,,,Other,Not Separately Reimbursable,68.41,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,68.41,82.5,,54.728,percent of total billed charges,Pays at 82.5% of total Billed charges,60.53,73,,48.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.04,70,,46.432,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.91,19.19,,12.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.46,50,,33.168,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.91,68.41,
"MICROSCOPIC ANALYSIS, LEVEL 6",14788309,CDM,310,RC,88311,HCPCS,Outpatient,,,115.58,115.58,,,,,,Other,Not Separately Reimbursable,95.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,95.35,82.5,,76.28,percent of total billed charges,Pays at 82.5% of total Billed charges,84.37,73,,67.496,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.91,70,,64.728,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.18,19.19,,17.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.79,50,,46.232,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.18,95.35,
DECALCIFICATION PROCEDURE,14788311,CDM,310,RC,88312,HCPCS,Outpatient,,,3.92,3.92,,,,,,Other,Not Separately Reimbursable,3.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.23,82.5,,2.584,percent of total billed charges,Pays at 82.5% of total Billed charges,2.86,73,,2.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.74,70,,2.192,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.75,19.19,,0.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.96,50,,1.568,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.75,3.23,
"SPECIAL STAINS, GROUP 1",14788312,CDM,310,RC,88313,HCPCS,Outpatient,,,36.17,36.17,,,,,,Other,Not Separately Reimbursable,29.84,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,29.84,82.5,,23.872,percent of total billed charges,Pays at 82.5% of total Billed charges,26.4,73,,21.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.32,70,,20.256,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.94,19.19,,5.552,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.09,50,,14.472,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.94,29.84,
"SPECIAL STAINS, GROUP 2",14788313,CDM,310,RC,88342,HCPCS,Outpatient,,,28.92,28.92,,,,,,Other,Not Separately Reimbursable,23.86,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.86,82.5,,19.088,percent of total billed charges,Pays at 82.5% of total Billed charges,21.11,73,,16.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.24,70,,16.192,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.55,19.19,,4.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.46,50,,11.568,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.55,23.86,
IMMUNOHISTOCHEMISTRY/AB STAINS,14788342,CDM,310,RC,88360,HCPCS,Outpatient,,,34.54,34.54,,,,,,Other,Not Separately Reimbursable,28.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.5,82.5,,22.8,percent of total billed charges,Pays at 82.5% of total Billed charges,25.21,73,,20.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.18,70,,19.344,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.63,19.19,,5.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,50,,13.816,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.63,28.5,
TUMOR IMMUNOHISTOCHEMISTRY/MANUAL STAIN,14788360,CDM,310,RC,86003,HCPCS,Outpatient,,,37.08,37.08,,,,,,Other,Not Separately Reimbursable,30.59,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,30.59,82.5,,24.472,percent of total billed charges,Pays at 82.5% of total Billed charges,27.07,73,,21.656,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.96,70,,20.768,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.12,19.19,,5.696,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.54,50,,14.832,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.12,30.59,
"ALLERGEN PROFILE, FOOD-BASIC",14900001,CDM,301,RC,86003,HCPCS,Outpatient,,,36,36,,,,,,Other,Not Separately Reimbursable,29.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,29.7,82.5,,23.76,percent of total billed charges,Pays at 82.5% of total Billed charges,26.28,73,,21.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.2,70,,20.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,19.19,,5.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18,50,,14.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,29.7,
"ALLERGENS, AREA 3",14900002,CDM,301,RC,87177,HCPCS,Outpatient,,,139.36,139.36,,,,,,Other,Not Separately Reimbursable,114.97,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,114.97,82.5,,91.976,percent of total billed charges,Pays at 82.5% of total Billed charges,101.73,73,,81.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.55,70,,78.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.74,19.19,,21.392,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.68,50,,55.744,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.74,114.97,
GIARDIA w/ OC&P,14900004,CDM,302,RC,80346,HCPCS,Outpatient,,,165.25,165.25,,,,,,Other,Not Separately Reimbursable,136.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,136.33,82.5,,109.064,percent of total billed charges,Pays at 82.5% of total Billed charges,120.63,73,,96.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.68,70,,92.544,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.71,19.19,,25.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.63,50,,66.104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.71,136.33,
KLONOPIN (CLONAZEPAM),14900005,CDM,301,RC,80346,HCPCS,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
LORAZEPAM,14900006,CDM,301,RC,U0003,HCPCS,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,82.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,82.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,82.69,
COVID19 [MERS-COV] IN-HOUSE,15032127,CDM,301,RC,70336,HCPCS,Outpatient,,,205,205,,,,,,Other,Not Separately Reimbursable,169.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,169.13,82.5,,135.304,percent of total billed charges,Pays at 82.5% of total Billed charges,149.65,73,,119.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.5,70,,114.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,19.19,,31.472,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.5,50,,82,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,169.13,
MRI TMJ,16070336,CDM,611,RC,70540,HCPCS,Outpatient,,,3103,3103,,,,,,Other,Not Separately Reimbursable,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2265.19,73,,1812.152,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2172.1,70,,1737.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595.47,19.19,,476.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1551.5,50,,1241.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595.47,2265.19,
MRI ORBIT/FACE/NECK W/O CONTRAST,16070540,CDM,611,RC,70542,HCPCS,Outpatient,,,3106,3106,,,,,,Other,Not Separately Reimbursable,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2267.38,73,,1813.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2174.2,70,,1739.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,19.19,,476.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1553,50,,1242.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,2267.38,
MRI ORBIT/FACE/NECK WITH CONTRAST,16070542,CDM,611,RC,70543,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,2406.08,
MRI ORBIT/FACE/NECK WITH/WO CONTRAST,16070543,CDM,611,RC,70544,HCPCS,Outpatient,,,4026,4026,,,,,,Other,Not Separately Reimbursable,2352.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2352.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2938.98,73,,2351.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2818.2,70,,2254.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,19.19,,618.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2013,50,,1610.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,2938.98,
MRI ANGIOGRAPHY HEAD W/O CONTRAST,16070544,CDM,615,RC,70545,HCPCS,Outpatient,,,3106,3106,,,,,,Other,Not Separately Reimbursable,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2267.38,73,,1813.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2174.2,70,,1739.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,19.19,,476.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1553,50,,1242.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,2267.38,
MRI ANGIOGRAPHY HEAD WITH CONTRAST,16070545,CDM,615,RC,70546,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,2406.08,
MRI ANGIOGRAPHY HEAD W/WO CONTRAST,16070546,CDM,615,RC,70547,HCPCS,Outpatient,,,4026,4026,,,,,,Other,Not Separately Reimbursable,2352.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2352.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2938.98,73,,2351.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2818.2,70,,2254.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,19.19,,618.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2013,50,,1610.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,2938.98,
MRI ANGIOGRAPHY NECK W/O CONTRAST,16070547,CDM,615,RC,70548,HCPCS,Outpatient,,,3106,3106,,,,,,Other,Not Separately Reimbursable,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2267.38,73,,1813.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2174.2,70,,1739.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,19.19,,476.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1553,50,,1242.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,2267.38,
MRI ANGIOGRAPHY NECK W CONTRAST,16070548,CDM,615,RC,70549,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,2406.08,
MRI ANGIOGRAPHY NECK W/WO CONTRAST,16070549,CDM,615,RC,70551,HCPCS,Outpatient,,,4026,4026,,,,,,Other,Not Separately Reimbursable,2352.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2352.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2938.98,73,,2351.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2818.2,70,,2254.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,19.19,,618.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2013,50,,1610.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,2938.98,
MRI of brain stem without dye,16070551,CDM,611,RC,70552,HCPCS,Outpatient,,,3106,3106,,,,,,Other,Not Separately Reimbursable,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2267.38,73,,1813.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2174.2,70,,1739.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,19.19,,476.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1553,50,,1242.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,2267.38,
MRI BRAIN W CONTRAST,16070552,CDM,611,RC,70553,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,1411.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1411.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,2406.08,
MRI scan of brain before and after contrast,16070553,CDM,611,RC,71550,HCPCS,Outpatient,,,4026,4026,,,,,,Other,Not Separately Reimbursable,2612.33,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2612.33,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2938.98,73,,2351.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2818.2,70,,2254.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,19.19,,618.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2013,50,,1610.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,2938.98,
MRI CHEST W/O CONTRAST,16071550,CDM,610,RC,71551,HCPCS,Outpatient,,,2225,2225,,,,,,Other,Not Separately Reimbursable,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1624.25,73,,1299.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1557.5,70,,1246,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,426.98,19.19,,341.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1112.5,50,,890,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,426.98,1624.25,
MRI CHEST WITH CONTRAST,16071551,CDM,610,RC,71552,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,2406.08,
MRI CHEST WITH W/O CONTRAST,16071552,CDM,610,RC,71555,HCPCS,Outpatient,,,4026,4026,,,,,,Other,Not Separately Reimbursable,2352.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2352.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2938.98,73,,2351.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2818.2,70,,2254.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,19.19,,618.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2013,50,,1610.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,2938.98,
MRI ANGIO CHEST W OR W/O CONTRAST,16071555,CDM,618,RC,72141,HCPCS,Outpatient,,,3516,3516,,,,,,Other,Not Separately Reimbursable,2900.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2900.7,82.5,,2320.56,percent of total billed charges,Pays at 82.5% of total Billed charges,2566.68,73,,2053.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2461.2,70,,1968.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,674.72,19.19,,539.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1758,50,,1406.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,674.72,2900.7,
MRI of the neck or spine without dye,16072141,CDM,612,RC,72142,HCPCS,Outpatient,,,3103,3103,,,,,,Other,Not Separately Reimbursable,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2265.19,73,,1812.152,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2172.1,70,,1737.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595.47,19.19,,476.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1551.5,50,,1241.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595.47,2265.19,
MRI NECK/SPINE WITH CONTRAST,16072142,CDM,612,RC,72146,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,1411.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1411.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,2406.08,
MRI of chest and spine without dye,16072146,CDM,612,RC,72147,HCPCS,Outpatient,,,3103,3103,,,,,,Other,Not Separately Reimbursable,1305.42,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1305.42,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2265.19,73,,1812.152,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2172.1,70,,1737.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595.47,19.19,,476.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1551.5,50,,1241.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595.47,2265.19,
MRI CHEST/SPINE WITH CONTRAST,16072147,CDM,612,RC,72148,HCPCS,Outpatient,,,3263,3263,,,,,,Other,Not Separately Reimbursable,1411.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1411.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2381.99,73,,1905.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2284.1,70,,1827.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,626.17,19.19,,500.936,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1631.5,50,,1305.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,626.17,2381.99,
MRI scan of lower spinal canal,16072148,CDM,612,RC,72149,HCPCS,Outpatient,,,3103,3103,,,,,,Other,Not Separately Reimbursable,1305.42,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1305.42,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2265.19,73,,1812.152,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2172.1,70,,1737.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595.47,19.19,,476.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1551.5,50,,1241.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595.47,2265.19,
MRI LUMBAR SPINE WITH CONTRAST,16072149,CDM,612,RC,72156,HCPCS,Outpatient,,,3863,3863,,,,,,Other,Not Separately Reimbursable,1411.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1411.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2819.99,73,,2255.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2704.1,70,,2163.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,741.31,19.19,,593.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1931.5,50,,1545.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,741.31,2819.99,
MRI of neck/spine with and without dye,16072156,CDM,612,RC,72157,HCPCS,Outpatient,,,4026,4026,,,,,,Other,Not Separately Reimbursable,2612.33,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2612.33,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2938.98,73,,2351.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2818.2,70,,2254.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,19.19,,618.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2013,50,,1610.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,2938.98,
MRI of chest and spine with and without dye,16072157,CDM,612,RC,72158,HCPCS,Outpatient,,,4026,4026,,,,,,Other,Not Separately Reimbursable,2612.33,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2612.33,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2938.98,73,,2351.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2818.2,70,,2254.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,19.19,,618.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2013,50,,1610.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,2938.98,
MRI of lower back with and without dye,16072158,CDM,612,RC,72159,HCPCS,Outpatient,,,4026,4026,,,,,,Other,Not Separately Reimbursable,2612.33,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2612.33,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2938.98,73,,2351.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2818.2,70,,2254.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,19.19,,618.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2013,50,,1610.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,2938.98,
MRI ANGIO SPINE WITH W/O CONTRAST,16072159,CDM,618,RC,72195,HCPCS,Outpatient,,,3962,3962,,,,,,Other,Not Separately Reimbursable,3268.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3268.65,82.5,,2614.92,percent of total billed charges,Pays at 82.5% of total Billed charges,2892.26,73,,2313.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2773.4,70,,2218.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,760.31,19.19,,608.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1981,50,,1584.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,760.31,3268.65,
MRI of pelvis without dye,16072195,CDM,612,RC,72196,HCPCS,Outpatient,,,3106,3106,,,,,,Other,Not Separately Reimbursable,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2267.38,73,,1813.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2174.2,70,,1739.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,19.19,,476.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1553,50,,1242.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,2267.38,
MRI PELVIS WITH CONTRAST,16072196,CDM,612,RC,72197,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,2406.08,
MRI of pelvis before and after dye,16072197,CDM,612,RC,72198,HCPCS,Outpatient,,,4026,4026,,,,,,Other,Not Separately Reimbursable,2352.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2352.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2938.98,73,,2351.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2818.2,70,,2254.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,19.19,,618.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2013,50,,1610.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,2938.98,
MRI ANGIO PELVIS WITH W/O CONTRAST,16072198,CDM,618,RC,73218,HCPCS,Outpatient,,,3506,3506,,,,,,Other,Not Separately Reimbursable,2892.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2892.45,82.5,,2313.96,percent of total billed charges,Pays at 82.5% of total Billed charges,2559.38,73,,2047.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2454.2,70,,1963.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,672.8,19.19,,538.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1753,50,,1402.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,672.8,2892.45,
MRI UPPER EXT W/O CONTRAST RT,16073218,CDM,610,RC,73219,HCPCS,Outpatient,,,3106,3106,,,,,,Other,Not Separately Reimbursable,2562.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2562.45,82.5,,2049.96,percent of total billed charges,Pays at 82.5% of total Billed charges,2267.38,73,,1813.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2174.2,70,,1739.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,19.19,,476.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1553,50,,1242.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,2562.45,
MRI UPPER EXT WITH CONTRAST RT,16073219,CDM,610,RC,73220,HCPCS,Outpatient,,,928,928,,,,,,Other,Not Separately Reimbursable,765.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,765.6,82.5,,612.48,percent of total billed charges,Pays at 82.5% of total Billed charges,677.44,73,,541.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,649.6,70,,519.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,178.08,19.19,,142.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,464,50,,371.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,178.08,765.6,
MRI UPPER EXT WITH W/O CONTRAST RT,16073220,CDM,610,RC,73221,HCPCS,Outpatient,,,2987,2987,,,,,,Other,Not Separately Reimbursable,2464.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2464.28,82.5,,1971.424,percent of total billed charges,Pays at 82.5% of total Billed charges,2180.51,73,,1744.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2090.9,70,,1672.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,573.21,19.19,,458.568,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1493.5,50,,1194.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,573.21,2464.28,
MRI JOINT UPR EXTREM W/O CONTRAST RT,16073221,CDM,610,RC,73222,HCPCS,Outpatient,,,3106,3106,,,,,,Other,Not Separately Reimbursable,2562.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2562.45,82.5,,2049.96,percent of total billed charges,Pays at 82.5% of total Billed charges,2267.38,73,,1813.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2174.2,70,,1739.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,19.19,,476.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1553,50,,1242.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,2562.45,
MRI JOINT UPR EXTREM WITH CONTRAST RT,16073222,CDM,610,RC,73223,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,2719.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2719.2,82.5,,2175.36,percent of total billed charges,Pays at 82.5% of total Billed charges,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,2719.2,
MRI JOINT UPR EXTREM W W/O CONTRAST RT,16073223,CDM,610,RC,73225,HCPCS,Outpatient,,,4026,4026,,,,,,Other,Not Separately Reimbursable,3321.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3321.45,82.5,,2657.16,percent of total billed charges,Pays at 82.5% of total Billed charges,2938.98,73,,2351.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2818.2,70,,2254.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,19.19,,618.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2013,50,,1610.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,3321.45,
MRI ANGIO JOINT UPR EXTREM WITH W/O CONT,16073225,CDM,618,RC,73718,HCPCS,Outpatient,,,3913,3913,,,,,,Other,Not Separately Reimbursable,3228.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3228.23,82.5,,2582.584,percent of total billed charges,Pays at 82.5% of total Billed charges,2856.49,73,,2285.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2739.1,70,,2191.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,750.9,19.19,,600.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1956.5,50,,1565.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,750.9,3228.23,
MRI LWR EXT W/O CONTRAST RT,16073718,CDM,610,RC,73719,HCPCS,Outpatient,,,3106,3106,,,,,,Other,Not Separately Reimbursable,2562.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2562.45,82.5,,2049.96,percent of total billed charges,Pays at 82.5% of total Billed charges,2267.38,73,,1813.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2174.2,70,,1739.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,19.19,,476.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1553,50,,1242.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,2562.45,
MRI LWR EXT WITH CONTRAST RT,16073719,CDM,610,RC,73720,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,2719.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2719.2,82.5,,2175.36,percent of total billed charges,Pays at 82.5% of total Billed charges,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,2719.2,
MRI LWR EXT WITH W/O CONTRAST RT,16073720,CDM,610,RC,73721,HCPCS,Outpatient,,,4026,4026,,,,,,Other,Not Separately Reimbursable,3321.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3321.45,82.5,,2657.16,percent of total billed charges,Pays at 82.5% of total Billed charges,2938.98,73,,2351.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2818.2,70,,2254.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,19.19,,618.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2013,50,,1610.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,3321.45,
MRI JNT LWR EXTREM W/O CONTRAST RT,16073721,CDM,610,RC,73722,HCPCS,Outpatient,,,3451,3451,,,,,,Other,Not Separately Reimbursable,2847.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2847.08,82.5,,2277.664,percent of total billed charges,Pays at 82.5% of total Billed charges,2519.23,73,,2015.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2415.7,70,,1932.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,662.25,19.19,,529.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1725.5,50,,1380.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,662.25,2847.08,
MRI JNT LWR EXTREM WITH CONTRAST RT,16073722,CDM,612,RC,73723,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,2719.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2719.2,82.5,,2175.36,percent of total billed charges,Pays at 82.5% of total Billed charges,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,2719.2,
MRI JNT LWR EXTREM WITH W/O CONTRAST RT,16073723,CDM,614,RC,73725,HCPCS,Outpatient,,,4026,4026,,,,,,Other,Not Separately Reimbursable,3321.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3321.45,82.5,,2657.16,percent of total billed charges,Pays at 82.5% of total Billed charges,2938.98,73,,2351.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2818.2,70,,2254.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,19.19,,618.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2013,50,,1610.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,3321.45,
MRI ANGIO LWR EXTREM W OR W/O CONTRAST,16073725,CDM,616,RC,74181,HCPCS,Outpatient,,,3508,3508,,,,,,Other,Not Separately Reimbursable,1273.83,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1273.83,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2560.84,73,,2048.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2455.6,70,,1964.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,673.19,19.19,,538.552,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1754,50,,1403.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,673.19,2560.84,
MRI of abdomen without dye,16074181,CDM,614,RC,74182,HCPCS,Outpatient,,,3103,3103,,,,,,Other,Not Separately Reimbursable,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2265.19,73,,1812.152,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2172.1,70,,1737.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595.47,19.19,,476.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1551.5,50,,1241.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595.47,2265.19,
MRI ABD WITH CONTRAST,16074182,CDM,614,RC,74183,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1176.08,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,2406.08,
MRI of abdomen without and with dye,16074183,CDM,614,RC,74185,HCPCS,Outpatient,,,4026,4026,,,,,,Other,Not Separately Reimbursable,2352.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2352.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2938.98,73,,2351.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2818.2,70,,2254.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,19.19,,618.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2013,50,,1610.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,2938.98,
MRI ANGIO ABD WITH W/O CONTRAST,16074185,CDM,618,RC,S8037,HCPCS,Outpatient,,,3499,3499,,,,,,Other,Not Separately Reimbursable,2886.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2886.68,82.5,,2309.344,percent of total billed charges,Pays at 82.5% of total Billed charges,2554.27,73,,2043.416,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2449.3,70,,1959.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,671.46,19.19,,537.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1749.5,50,,1399.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,671.46,2886.68,
MRI CHOLANGIOPANCREATOGRAPHY,16078037,CDM,614,RC,73218,HCPCS,Outpatient,,,1500,1500,,,,,,Other,Not Separately Reimbursable,1237.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1237.5,82.5,,990,percent of total billed charges,Pays at 82.5% of total Billed charges,1095,73,,876,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1050,70,,840,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,287.85,19.19,,230.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,750,50,,600,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,287.85,1237.5,
MRI UPPER EXT W/O CONTRAST LT,16173218,CDM,610,RC,73219,HCPCS,Outpatient,,,3106,3106,,,,,,Other,Not Separately Reimbursable,2562.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2562.45,82.5,,2049.96,percent of total billed charges,Pays at 82.5% of total Billed charges,2267.38,73,,1813.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2174.2,70,,1739.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,19.19,,476.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1553,50,,1242.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,2562.45,
MRI UPPER EXT WITH CONTRAST LT,16173219,CDM,610,RC,73220,HCPCS,Outpatient,,,928,928,,,,,,Other,Not Separately Reimbursable,765.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,765.6,82.5,,612.48,percent of total billed charges,Pays at 82.5% of total Billed charges,677.44,73,,541.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,649.6,70,,519.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,178.08,19.19,,142.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,464,50,,371.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,178.08,765.6,
MRI UPPER EXT WITH W/O CONTRAST LT,16173220,CDM,610,RC,73221,HCPCS,Outpatient,,,2987,2987,,,,,,Other,Not Separately Reimbursable,2464.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2464.28,82.5,,1971.424,percent of total billed charges,Pays at 82.5% of total Billed charges,2180.51,73,,1744.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2090.9,70,,1672.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,573.21,19.19,,458.568,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1493.5,50,,1194.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,573.21,2464.28,
MRI JOINT UPR EXTREM W/O CONTRAST LT,16173221,CDM,610,RC,73222,HCPCS,Outpatient,,,3106,3106,,,,,,Other,Not Separately Reimbursable,2562.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2562.45,82.5,,2049.96,percent of total billed charges,Pays at 82.5% of total Billed charges,2267.38,73,,1813.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2174.2,70,,1739.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,19.19,,476.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1553,50,,1242.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,2562.45,
MRI JOINT UPR EXTREM WITH CONTRAST LT,16173222,CDM,614,RC,73223,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,2719.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2719.2,82.5,,2175.36,percent of total billed charges,Pays at 82.5% of total Billed charges,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,2719.2,
MRI JOINT UPR EXTREM W W/O CONTRAST LT,16173223,CDM,614,RC,73718,HCPCS,Outpatient,,,4026,4026,,,,,,Other,Not Separately Reimbursable,3321.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3321.45,82.5,,2657.16,percent of total billed charges,Pays at 82.5% of total Billed charges,2938.98,73,,2351.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2818.2,70,,2254.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,19.19,,618.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2013,50,,1610.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,3321.45,
MRI LWR EXT W/O CONTRAST LT,16173718,CDM,610,RC,73719,HCPCS,Outpatient,,,3106,3106,,,,,,Other,Not Separately Reimbursable,2562.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2562.45,82.5,,2049.96,percent of total billed charges,Pays at 82.5% of total Billed charges,2267.38,73,,1813.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2174.2,70,,1739.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,19.19,,476.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1553,50,,1242.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.04,2562.45,
MRI LWR EXT WITH CONTRAST LT,16173719,CDM,614,RC,73720,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,2719.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2719.2,82.5,,2175.36,percent of total billed charges,Pays at 82.5% of total Billed charges,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,2719.2,
MRI LWR EXT WITH W/O CONTRAST LT,16173720,CDM,610,RC,73721,HCPCS,Outpatient,,,4026,4026,,,,,,Other,Not Separately Reimbursable,3321.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3321.45,82.5,,2657.16,percent of total billed charges,Pays at 82.5% of total Billed charges,2938.98,73,,2351.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2818.2,70,,2254.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,19.19,,618.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2013,50,,1610.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,3321.45,
MRI JNT LWR EXTREM W/O CONTRAST LT,16173721,CDM,610,RC,73722,HCPCS,Outpatient,,,3451,3451,,,,,,Other,Not Separately Reimbursable,2847.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2847.08,82.5,,2277.664,percent of total billed charges,Pays at 82.5% of total Billed charges,2519.23,73,,2015.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2415.7,70,,1932.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,662.25,19.19,,529.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1725.5,50,,1380.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,662.25,2847.08,
MRI JNT LWR EXTREM WITH CONTRAST LT,16173722,CDM,614,RC,73723,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,2719.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2719.2,82.5,,2175.36,percent of total billed charges,Pays at 82.5% of total Billed charges,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,2719.2,
MRI JNT LWR EXTREM WITH W/O CONTRAST LT,16173723,CDM,614,RC,93005,HCPCS,Outpatient,,,4026,4026,,,,,,Other,Not Separately Reimbursable,3321.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3321.45,82.5,,2657.16,percent of total billed charges,Pays at 82.5% of total Billed charges,2938.98,73,,2351.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2818.2,70,,2254.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,19.19,,618.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2013,50,,1610.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.59,3321.45,
ELECTROCARDIOGRAM,18042002,CDM,730,RC,93225,HCPCS,Outpatient,,,293,293,,,,,,Other,Not Separately Reimbursable,113.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,113.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,213.89,73,,171.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205.1,70,,164.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.23,19.19,,44.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,146.5,50,,117.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.23,213.89,
HOLTER RECORDING 24 HRS,18042003,CDM,731,RC,93226,HCPCS,Outpatient,,,403,403,,,,,,Other,Not Separately Reimbursable,315.16,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,315.16,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,294.19,73,,235.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,282.1,70,,225.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.34,19.19,,61.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,201.5,50,,161.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.34,315.16,
HOLTER ANALYSIS,18042004,CDM,731,RC,93225,HCPCS,Outpatient,,,439,439,,,,,,Other,Not Separately Reimbursable,555.98,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,555.98,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,320.47,73,,256.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,307.3,70,,245.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.24,19.19,,67.392,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,219.5,50,,175.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.24,555.98,
HOLTER RECORDING 48 HRS.,18042006,CDM,731,RC,93017,HCPCS,Outpatient,,,727,727,,,,,,Other,Not Separately Reimbursable,315.16,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,315.16,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,530.71,73,,424.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,508.9,70,,407.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.51,19.19,,111.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,363.5,50,,290.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.51,530.71,
TREADMILL STRESS TEST,18042044,CDM,482,RC,95819,HCPCS,Outpatient,,,873,873,,,,,,Other,Not Separately Reimbursable,426.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,426.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,637.29,73,,509.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,611.1,70,,488.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,167.53,19.19,,134.024,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,436.5,50,,349.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,167.53,637.29,
EEG,18043041,CDM,740,RC,93000,HCPCS,Outpatient,,,816,816,,,,,,Other,Not Separately Reimbursable,145.94,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,145.94,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,595.68,73,,476.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,571.2,70,,456.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,156.59,19.19,,125.272,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,408,50,,326.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,145.94,595.68,
Routine EKG using at least 12 leads including interpretation and report,18093000,CDM,730,RC,93015,HCPCS,Outpatient,,,355,355,,,,,,Other,Not Separately Reimbursable,292.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,292.88,82.5,,234.304,percent of total billed charges,Pays at 82.5% of total Billed charges,259.15,73,,207.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,248.5,70,,198.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.12,19.19,,54.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177.5,50,,142,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.12,292.88,
Test to determine heart abnormalities,18093015,CDM,482,RC,93229,HCPCS,Outpatient,,,1502,1502,,,,,,Other,Not Separately Reimbursable,1239.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1239.15,82.5,,991.32,percent of total billed charges,Pays at 82.5% of total Billed charges,1096.46,73,,877.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1051.4,70,,841.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,288.23,19.19,,230.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,751,50,,600.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,288.23,1239.15,
EVENT MONITOR TECHNICAL SUPPORT-MCR/COMM,18093229,CDM,730,RC,93270,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,54.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,54.45,82.5,,43.56,percent of total billed charges,Pays at 82.5% of total Billed charges,48.18,73,,38.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.2,70,,36.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,19.19,,10.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33,50,,26.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,54.45,
EVENT MONITOR RECORDING-MCD/BCBS,18093270,CDM,730,RC,93224,HCPCS,Outpatient,,,402,402,,,,,,Other,Not Separately Reimbursable,331.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,331.65,82.5,,265.32,percent of total billed charges,Pays at 82.5% of total Billed charges,293.46,73,,234.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,281.4,70,,225.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.14,19.19,,61.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,201,50,,160.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.14,331.65,
"HOLTER RECORDING W/ANALY,INTER & RPT 48H",18193224,CDM,731,RC,70260,HCPCS,Outpatient,,,1166,1166,,,,,,Other,Not Separately Reimbursable,961.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,961.95,82.5,,769.56,percent of total billed charges,Pays at 82.5% of total Billed charges,851.18,73,,680.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,816.2,70,,652.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,223.76,19.19,,179.008,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,583,50,,466.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,223.76,961.95,
SKULL COMP.4+VIEWS W/WO STEREO,20050013,CDM,320,RC,70220,HCPCS,Outpatient,,,533,533,,,,,,Other,Not Separately Reimbursable,94.63,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,94.63,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,389.09,73,,311.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,373.1,70,,298.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.28,19.19,,81.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,266.5,50,,213.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.63,389.09,
SINUSES COMP.3+VIEWS,20050039,CDM,320,RC,70030,HCPCS,Outpatient,,,592,592,,,,,,Other,Not Separately Reimbursable,83.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,83.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,432.16,73,,345.728,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,414.4,70,,331.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,113.6,19.19,,90.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,296,50,,236.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.03,432.16,
EYE FOREIGN BODY,20050054,CDM,320,RC,70120,HCPCS,Outpatient,,,352,352,,,,,,Other,Not Separately Reimbursable,44.79,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,44.79,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,256.96,73,,205.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,246.4,70,,197.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.55,19.19,,54.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176,50,,140.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.79,256.96,
MASTOIDS LTD<3 VIEWS,20050070,CDM,320,RC,70160,HCPCS,Outpatient,,,451,451,,,,,,Other,Not Separately Reimbursable,65.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,329.23,73,,263.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,315.7,70,,252.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.55,19.19,,69.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,225.5,50,,180.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.43,329.23,
NASAL BONE COMP.3+VIEWS,20050088,CDM,320,RC,70200,HCPCS,Outpatient,,,427,427,,,,,,Other,Not Separately Reimbursable,54.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,311.71,73,,249.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,298.9,70,,239.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.94,19.19,,65.552,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,213.5,50,,170.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.84,311.71,
ORBITS COMP.4+VIEWS,20050096,CDM,320,RC,70190,HCPCS,Outpatient,,,526,526,,,,,,Other,Not Separately Reimbursable,83.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,83.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,383.98,73,,307.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,368.2,70,,294.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.94,19.19,,80.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,263,50,,210.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.03,383.98,
OPTIC FORAMINA,20050104,CDM,320,RC,70150,HCPCS,Outpatient,,,440,440,,,,,,Other,Not Separately Reimbursable,65.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,321.2,73,,256.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,308,70,,246.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.44,19.19,,67.552,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,220,50,,176,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.43,321.2,
FACIAL BONES COMP.3+VIEWS,20050120,CDM,320,RC,70250,HCPCS,Outpatient,,,675,675,,,,,,Other,Not Separately Reimbursable,83.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,83.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,492.75,73,,394.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,472.5,70,,378,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,129.53,19.19,,103.624,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,337.5,50,,270,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.03,492.75,
SKULL<4 VIEWS W/WO STEREO,20050138,CDM,320,RC,74022,HCPCS,Outpatient,,,434,434,,,,,,Other,Not Separately Reimbursable,65.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,316.82,73,,253.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,303.8,70,,243.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.28,19.19,,66.624,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,217,50,,173.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.43,316.82,
Serial radiologic examination of the abdomen,20050146,CDM,320,RC,71120,HCPCS,Outpatient,,,773,773,,,,,,Other,Not Separately Reimbursable,77.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,77.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,564.29,73,,451.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,541.1,70,,432.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.34,19.19,,118.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,386.5,50,,309.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.99,564.29,
STERNUM >2VIEWS,20051094,CDM,320,RC,71101,HCPCS,Outpatient,,,451,451,,,,,,Other,Not Separately Reimbursable,68.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,68.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,329.23,73,,263.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,315.7,70,,252.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.55,19.19,,69.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,225.5,50,,180.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.45,329.23,
RIBS RT 3+VIEWS,20051102,CDM,320,RC,71111,HCPCS,Outpatient,,,700,700,,,,,,Other,Not Separately Reimbursable,577.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,577.5,82.5,,462,percent of total billed charges,Pays at 82.5% of total Billed charges,511,73,,408.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,490,70,,392,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,134.33,19.19,,107.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,350,50,,280,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,134.33,577.5,
RIBS WITH CHEST 4+ VIEWS,20051110,CDM,320,RC,72040,HCPCS,Outpatient,,,773,773,,,,,,Other,Not Separately Reimbursable,94.63,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,94.63,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,564.29,73,,451.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,541.1,70,,432.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.34,19.19,,118.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,386.5,50,,309.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.63,564.29,
"Radiologic examination of the neck/spine, 2-3 views",20052019,CDM,320,RC,72050,HCPCS,Outpatient,,,474,474,,,,,,Other,Not Separately Reimbursable,63.41,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,63.41,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,346.02,73,,276.816,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,331.8,70,,265.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.96,19.19,,72.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,237,50,,189.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.41,346.02,
"Radiologic examination of the neck/spine, 4-5 views",20052027,CDM,320,RC,72052,HCPCS,Outpatient,,,643,643,,,,,,Other,Not Separately Reimbursable,94.63,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,94.63,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,469.39,73,,375.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,450.1,70,,360.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,123.39,19.19,,98.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,321.5,50,,257.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.63,469.39,
SPINE CERVICAL COMPLETE,20052035,CDM,320,RC,72110,HCPCS,Outpatient,,,773,773,,,,,,Other,Not Separately Reimbursable,119.26,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,119.26,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,564.29,73,,451.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,541.1,70,,432.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.34,19.19,,118.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,386.5,50,,309.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,119.26,564.29,
"X-ray of lower and sacral spine, minimum of 4 views",20052043,CDM,320,RC,72100,HCPCS,Outpatient,,,742,742,,,,,,Other,Not Separately Reimbursable,96.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,96.61,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,541.66,73,,433.328,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,519.4,70,,415.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,142.39,19.19,,113.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371,50,,296.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.61,541.66,
X-ray of the lower spine 2-3 views,20052050,CDM,320,RC,72072,HCPCS,Outpatient,,,504,504,,,,,,Other,Not Separately Reimbursable,70.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,70.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,367.92,73,,294.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,352.8,70,,282.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.72,19.19,,77.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252,50,,201.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.47,367.92,
"Radiologic examination of the middle spine, 3 views",20052068,CDM,320,RC,74246,HCPCS,Outpatient,,,469,469,,,,,,Other,Not Separately Reimbursable,77.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,77.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,342.37,73,,273.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,328.3,70,,262.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90,19.19,,72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,234.5,50,,187.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.99,342.37,
GI SERIES W AIR CONTRAST,20053018,CDM,320,RC,74245,HCPCS,Outpatient,,,1048,1048,,,,,,Other,Not Separately Reimbursable,173.12,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,173.12,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,765.04,73,,612.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,733.6,70,,586.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,201.11,19.19,,160.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,524,50,,419.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,173.12,765.04,
GI SERIES W S/B,20053019,CDM,320,RC,74220,HCPCS,Outpatient,,,1602,1602,,,,,,Other,Not Separately Reimbursable,1321.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1321.65,82.5,,1057.32,percent of total billed charges,Pays at 82.5% of total Billed charges,1169.46,73,,935.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1121.4,70,,897.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,307.42,19.19,,245.936,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,801,50,,640.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,307.42,1321.65,
BARIUM SWALLOW ESOPHAGUS,20053025,CDM,320,RC,74250,HCPCS,Outpatient,,,747,747,,,,,,Other,Not Separately Reimbursable,124.3,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,124.3,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,545.31,73,,436.248,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,522.9,70,,418.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.35,19.19,,114.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,373.5,50,,298.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124.3,545.31,
SMALL/BOWEL WITH MULTIPLE SERIES,20053033,CDM,320,RC,74270,HCPCS,Outpatient,,,1011,1011,,,,,,Other,Not Separately Reimbursable,136.87,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,136.87,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,738.03,73,,590.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,707.7,70,,566.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,194.01,19.19,,155.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,505.5,50,,404.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,136.87,738.03,
BARIUM ENEMA COLON,20053041,CDM,320,RC,74280,HCPCS,Outpatient,,,876,876,,,,,,Other,Not Separately Reimbursable,179.64,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,179.64,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,639.48,73,,511.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,613.2,70,,490.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,168.1,19.19,,134.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,438,50,,350.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,168.1,639.48,
BARIUM ENEMA COLON W AIR CONTRAST,20053058,CDM,320,RC,73050,HCPCS,Outpatient,,,1159,1159,,,,,,Other,Not Separately Reimbursable,235.53,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,235.53,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,846.07,73,,676.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,811.3,70,,649.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,222.41,19.19,,177.928,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,579.5,50,,463.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,222.41,846.07,
A-C JOINTS BILATERAL,20053132,CDM,320,RC,76000,HCPCS,Outpatient,,,335,335,,,,,,Other,Not Separately Reimbursable,70.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,70.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,244.55,73,,195.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,234.5,70,,187.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.29,19.19,,51.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,167.5,50,,134,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.29,244.55,
"Flouroscopy, or x-ray ""movie"" that takes less than an hour",20054005,CDM,320,RC,73020,HCPCS,Outpatient,,,1049,1049,,,,,,Other,Not Separately Reimbursable,136.87,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,136.87,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,765.77,73,,612.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,734.3,70,,587.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,201.3,19.19,,161.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,524.5,50,,419.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,136.87,765.77,
SHOULDER RT 1 VIEW,20054015,CDM,320,RC,73030,HCPCS,Outpatient,,,185,185,,,,,,Other,Not Separately Reimbursable,152.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,152.63,82.5,,122.104,percent of total billed charges,Pays at 82.5% of total Billed charges,135.05,73,,108.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,129.5,70,,103.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,19.19,,28.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.5,50,,74,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,152.63,
SHOULDER RT 2+VIEWS COMPLETE,20054023,CDM,320,RC,73010,HCPCS,Outpatient,,,515,515,,,,,,Other,Not Separately Reimbursable,424.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,424.88,82.5,,339.904,percent of total billed charges,Pays at 82.5% of total Billed charges,375.95,73,,300.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,360.5,70,,288.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.83,19.19,,79.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,257.5,50,,206,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.83,424.88,
SCAPULA RT COMPLETE,20054031,CDM,320,RC,73000,HCPCS,Outpatient,,,577,577,,,,,,Other,Not Separately Reimbursable,476.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,476.03,82.5,,380.824,percent of total billed charges,Pays at 82.5% of total Billed charges,421.21,73,,336.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,403.9,70,,323.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110.73,19.19,,88.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,288.5,50,,230.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110.73,476.03,
CLAVICLE-RT COMP,20054049,CDM,320,RC,73060,HCPCS,Outpatient,,,525,525,,,,,,Other,Not Separately Reimbursable,433.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,433.13,82.5,,346.504,percent of total billed charges,Pays at 82.5% of total Billed charges,383.25,73,,306.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,367.5,70,,294,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.75,19.19,,80.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,262.5,50,,210,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.75,433.13,
HUMERUS RT 2+VIEWS,20054056,CDM,320,RC,73080,HCPCS,Outpatient,,,433,433,,,,,,Other,Not Separately Reimbursable,357.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,357.23,82.5,,285.784,percent of total billed charges,Pays at 82.5% of total Billed charges,316.09,73,,252.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,303.1,70,,242.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.09,19.19,,66.472,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216.5,50,,173.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.09,357.23,
ELBOW RT 3+VIEWS,20054064,CDM,320,RC,73090,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
FOREARM-RT 2VIEWS,20054072,CDM,320,RC,73092,HCPCS,Outpatient,,,464,464,,,,,,Other,Not Separately Reimbursable,382.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,382.8,82.5,,306.24,percent of total billed charges,Pays at 82.5% of total Billed charges,338.72,73,,270.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,324.8,70,,259.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.04,19.19,,71.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,232,50,,185.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.04,382.8,
UPPER EXT INFANT 2+VIEWS,20054073,CDM,320,RC,73110,HCPCS,Outpatient,,,393,393,,,,,,Other,Not Separately Reimbursable,51.85,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.85,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,286.89,73,,229.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,275.1,70,,220.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75.42,19.19,,60.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,196.5,50,,157.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.85,286.89,
WRIST RT 3VIEWS COMP,20054080,CDM,320,RC,72114,HCPCS,Outpatient,,,480,480,,,,,,Other,Not Separately Reimbursable,396,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,396,82.5,,316.8,percent of total billed charges,Pays at 82.5% of total Billed charges,350.4,73,,280.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,336,70,,268.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.11,19.19,,73.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,240,50,,192,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.11,396,
SPINE LUMB COMP W BENDING,20054081,CDM,320,RC,70360,HCPCS,Outpatient,,,849,849,,,,,,Other,Not Separately Reimbursable,124.3,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,124.3,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,619.77,73,,495.816,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,594.3,70,,475.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,162.92,19.19,,130.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,424.5,50,,339.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124.3,619.77,
NECK SOFT TISSUE,20054083,CDM,320,RC,73130,HCPCS,Outpatient,,,443,443,,,,,,Other,Not Separately Reimbursable,44.79,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,44.79,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,323.39,73,,258.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,310.1,70,,248.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85.01,19.19,,68.008,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,221.5,50,,177.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.79,323.39,
HAND RT 3+VIEWS COMPLETE,20054098,CDM,320,RC,73140,HCPCS,Outpatient,,,530,530,,,,,,Other,Not Separately Reimbursable,437.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,437.25,82.5,,349.8,percent of total billed charges,Pays at 82.5% of total Billed charges,386.9,73,,309.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371,70,,296.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,19.19,,81.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,265,50,,212,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,437.25,
FINGER RT 2+VIEWS,20054106,CDM,320,RC,72202,HCPCS,Outpatient,,,427,427,,,,,,Other,Not Separately Reimbursable,352.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,352.28,82.5,,281.824,percent of total billed charges,Pays at 82.5% of total Billed charges,311.71,73,,249.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,298.9,70,,239.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.94,19.19,,65.552,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,213.5,50,,170.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.94,352.28,
SACROILIAC JTS 3+VIEWS,20055038,CDM,320,RC,73560,HCPCS,Outpatient,,,361,361,,,,,,Other,Not Separately Reimbursable,65.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,263.53,73,,210.824,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.7,70,,202.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.28,19.19,,55.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.5,50,,144.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.43,263.53,
KNEE RT 1-2 VIEWS,20055053,CDM,320,RC,73564,HCPCS,Outpatient,,,370,370,,,,,,Other,Not Separately Reimbursable,305.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,305.25,82.5,,244.2,percent of total billed charges,Pays at 82.5% of total Billed charges,270.1,73,,216.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,259,70,,207.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,19.19,,56.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,185,50,,148,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,305.25,
KNEE RT 4 VIEWS COMPLETE,20055061,CDM,320,RC,73610,HCPCS,Outpatient,,,570,570,,,,,,Other,Not Separately Reimbursable,470.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,470.25,82.5,,376.2,percent of total billed charges,Pays at 82.5% of total Billed charges,416.1,73,,332.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,399,70,,319.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.38,19.19,,87.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,285,50,,228,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.38,470.25,
ANKLE RT 3+VIEWS COMPLETE,20055079,CDM,320,RC,73650,HCPCS,Outpatient,,,525,525,,,,,,Other,Not Separately Reimbursable,433.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,433.13,82.5,,346.504,percent of total billed charges,Pays at 82.5% of total Billed charges,383.25,73,,306.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,367.5,70,,294,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.75,19.19,,80.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,262.5,50,,210,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.75,433.13,
HEEL/CALC RT 2+VIEWS,20055095,CDM,320,RC,73630,HCPCS,Outpatient,,,422,422,,,,,,Other,Not Separately Reimbursable,348.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,348.15,82.5,,278.52,percent of total billed charges,Pays at 82.5% of total Billed charges,308.06,73,,246.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,295.4,70,,236.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.98,19.19,,64.784,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,211,50,,168.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.98,348.15,
FOOT RT 3+VIEWS COMPLETE,20055103,CDM,320,RC,73660,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
TOE RT 2+VIEWS,20055111,CDM,320,RC,73592,HCPCS,Outpatient,,,319,319,,,,,,Other,Not Separately Reimbursable,263.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,263.18,82.5,,210.544,percent of total billed charges,Pays at 82.5% of total Billed charges,232.87,73,,186.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,223.3,70,,178.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.22,19.19,,48.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,159.5,50,,127.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.22,263.18,
LOWER EXT RT INFANT 2VIEWS,20055130,CDM,320,RC,72170,HCPCS,Outpatient,,,399,399,,,,,,Other,Not Separately Reimbursable,329.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,329.18,82.5,,263.344,percent of total billed charges,Pays at 82.5% of total Billed charges,291.27,73,,233.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,279.3,70,,223.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.57,19.19,,61.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,199.5,50,,159.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.57,329.18,
Radiologic examination of the pelvis,20055152,CDM,320,RC,74400,HCPCS,Outpatient,,,567,567,,,,,,Other,Not Separately Reimbursable,54.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,413.91,73,,331.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,396.9,70,,317.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108.81,19.19,,87.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,283.5,50,,226.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.84,413.91,
IVP IV PYELOGRAPHY,20056010,CDM,320,RC,72220,HCPCS,Outpatient,,,1064,1064,,,,,,Other,Not Separately Reimbursable,177.66,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,177.66,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,776.72,73,,621.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,744.8,70,,595.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,204.18,19.19,,163.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,532,50,,425.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177.66,776.72,
SACRUM/COCCYX 2+VIEWS,20056499,CDM,320,RC,71130,HCPCS,Outpatient,,,438,438,,,,,,Other,Not Separately Reimbursable,60.39,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,60.39,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,319.74,73,,255.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,306.6,70,,245.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.05,19.19,,67.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,219,50,,175.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.39,319.74,
STERNOCLAVICULAR JOINT (S) > 3VIEWS,20056507,CDM,320,RC,73590,HCPCS,Outpatient,,,283,283,,,,,,Other,Not Separately Reimbursable,73.46,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,73.46,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,206.59,73,,165.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,198.1,70,,158.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.31,19.19,,43.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,141.5,50,,113.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.31,206.59,
TIB/FIB RT 2 VIEWS,20056531,CDM,320,RC,77075,HCPCS,Outpatient,,,489,489,,,,,,Other,Not Separately Reimbursable,403.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,403.43,82.5,,322.744,percent of total billed charges,Pays at 82.5% of total Billed charges,356.97,73,,285.576,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,342.3,70,,273.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.84,19.19,,75.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,244.5,50,,195.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.84,403.43,
BONE SURVEY METASTASES COMPLETE,20056598,CDM,320,RC,77072,HCPCS,Outpatient,,,1639,1639,,,,,,Other,Not Separately Reimbursable,151.48,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,151.48,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1196.47,73,,957.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1147.3,70,,917.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,314.52,19.19,,251.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,819.5,50,,655.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.48,1196.47,
BONE AGE STUDIES,20057001,CDM,320,RC,77076,HCPCS,Outpatient,,,248,248,,,,,,Other,Not Separately Reimbursable,54.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,181.04,73,,144.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,173.6,70,,138.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.59,19.19,,38.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124,50,,99.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.59,181.04,
BONE SURVEY METASTASES INFANT,20057002,CDM,320,RC,73070,HCPCS,Outpatient,,,1007,1007,,,,,,Other,Not Separately Reimbursable,77.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,77.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,735.11,73,,588.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,704.9,70,,563.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,193.24,19.19,,154.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,503.5,50,,402.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.99,735.11,
ELBOW RT 2VIEWS,20057004,CDM,320,RC,70140,HCPCS,Outpatient,,,358,358,,,,,,Other,Not Separately Reimbursable,295.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,295.35,82.5,,236.28,percent of total billed charges,Pays at 82.5% of total Billed charges,261.34,73,,209.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,250.6,70,,200.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.7,19.19,,54.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179,50,,143.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.7,295.35,
FACIAL BONES LTD<3VIEWS,20057005,CDM,320,RC,73620,HCPCS,Outpatient,,,358,358,,,,,,Other,Not Separately Reimbursable,65.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,261.34,73,,209.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,250.6,70,,200.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.7,19.19,,54.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179,50,,143.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.43,261.34,
FOOT RT 2VIEWS,20057006,CDM,320,RC,73120,HCPCS,Outpatient,,,439,439,,,,,,Other,Not Separately Reimbursable,362.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,362.18,82.5,,289.744,percent of total billed charges,Pays at 82.5% of total Billed charges,320.47,73,,256.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,307.3,70,,245.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.24,19.19,,67.392,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,219.5,50,,175.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.24,362.18,
HAND RT 2 VIEWS,20057007,CDM,320,RC,73562,HCPCS,Outpatient,,,341,341,,,,,,Other,Not Separately Reimbursable,281.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,281.33,82.5,,225.064,percent of total billed charges,Pays at 82.5% of total Billed charges,248.93,73,,199.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,238.7,70,,190.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.44,19.19,,52.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.5,50,,136.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.44,281.33,
KNEE/PATELLA RT 3VIEWS,20057010,CDM,320,RC,70130,HCPCS,Outpatient,,,462,462,,,,,,Other,Not Separately Reimbursable,381.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,381.15,82.5,,304.92,percent of total billed charges,Pays at 82.5% of total Billed charges,337.26,73,,269.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,323.4,70,,258.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.66,19.19,,70.928,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,231,50,,184.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.66,381.15,
MASTOIDS COMP 3+VIEWS,20057012,CDM,320,RC,77073,HCPCS,Outpatient,,,683,683,,,,,,Other,Not Separately Reimbursable,83.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,83.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,498.59,73,,398.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,478.1,70,,382.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,131.07,19.19,,104.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,341.5,50,,273.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.03,498.59,
BONE LENGTH STUDIES SCANOGRAM,20057013,CDM,320,RC,70210,HCPCS,Outpatient,,,196,196,,,,,,Other,Not Separately Reimbursable,83.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,83.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,143.08,73,,114.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.2,70,,109.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.61,19.19,,30.088,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,50,,78.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.61,143.08,
SINUSES<3VIEWS,20057014,CDM,320,RC,72020,HCPCS,Outpatient,,,387,387,,,,,,Other,Not Separately Reimbursable,65.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,282.51,73,,226.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,270.9,70,,216.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.27,19.19,,59.416,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,193.5,50,,154.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.43,282.51,
SPINE LUMBAR 1VIEW,20057015,CDM,320,RC,72020,HCPCS,Outpatient,,,294,294,,,,,,Other,Not Separately Reimbursable,44.79,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,44.79,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,214.62,73,,171.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205.8,70,,164.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.42,19.19,,45.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,50,,117.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.79,214.62,
SPINE CERVICAL 1 VIEW,20057016,CDM,320,RC,72020,HCPCS,Outpatient,,,294,294,,,,,,Other,Not Separately Reimbursable,44.79,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,44.79,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,214.62,73,,171.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205.8,70,,164.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.42,19.19,,45.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,50,,117.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.79,214.62,
SPINE THORACIC 1 VIEW,20057017,CDM,320,RC,72070,HCPCS,Outpatient,,,294,294,,,,,,Other,Not Separately Reimbursable,44.79,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,44.79,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,214.62,73,,171.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205.8,70,,164.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.42,19.19,,45.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,50,,117.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.79,214.62,
"Radiologic examination of the middle spine, 2 views",20057018,CDM,320,RC,73100,HCPCS,Outpatient,,,259,259,,,,,,Other,Not Separately Reimbursable,68.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,68.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,189.07,73,,151.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,181.3,70,,145.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,19.19,,39.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,129.5,50,,103.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,189.07,
WRIST RT 2VIEWS,20057019,CDM,320,RC,73600,HCPCS,Outpatient,,,381,381,,,,,,Other,Not Separately Reimbursable,314.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,314.33,82.5,,251.464,percent of total billed charges,Pays at 82.5% of total Billed charges,278.13,73,,222.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,266.7,70,,213.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.11,19.19,,58.488,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,190.5,50,,152.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.11,314.33,
ANKLE RT 2VIEWS,20057021,CDM,320,RC,74230,HCPCS,Outpatient,,,381,381,,,,,,Other,Not Separately Reimbursable,314.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,314.33,82.5,,251.464,percent of total billed charges,Pays at 82.5% of total Billed charges,278.13,73,,222.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,266.7,70,,213.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.11,19.19,,58.488,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,190.5,50,,152.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.11,314.33,
BARIUM SW W VIDEO,20057022,CDM,320,RC,73600,HCPCS,Outpatient,,,992,992,,,,,,Other,Not Separately Reimbursable,136.87,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,136.87,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,724.16,73,,579.328,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,694.4,70,,555.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,190.36,19.19,,152.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,496,50,,396.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,136.87,724.16,
ANKLE LT 2 VIEWS,20057023,CDM,320,RC,73610,HCPCS,Outpatient,,,381,381,,,,,,Other,Not Separately Reimbursable,314.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,314.33,82.5,,251.464,percent of total billed charges,Pays at 82.5% of total Billed charges,278.13,73,,222.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,266.7,70,,213.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.11,19.19,,58.488,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,190.5,50,,152.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.11,314.33,
ANKLE LT 3+VIEWS COMPLETE,20057024,CDM,320,RC,73000,HCPCS,Outpatient,,,525,525,,,,,,Other,Not Separately Reimbursable,433.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,433.13,82.5,,346.504,percent of total billed charges,Pays at 82.5% of total Billed charges,383.25,73,,306.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,367.5,70,,294,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.75,19.19,,80.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,262.5,50,,210,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.75,433.13,
CLAVICLE-LT COMPLETE,20057025,CDM,320,RC,73070,HCPCS,Outpatient,,,525,525,,,,,,Other,Not Separately Reimbursable,433.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,433.13,82.5,,346.504,percent of total billed charges,Pays at 82.5% of total Billed charges,383.25,73,,306.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,367.5,70,,294,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.75,19.19,,80.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,262.5,50,,210,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.75,433.13,
ELBOW-LT 2VIEWS,20057026,CDM,320,RC,73080,HCPCS,Outpatient,,,358,358,,,,,,Other,Not Separately Reimbursable,295.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,295.35,82.5,,236.28,percent of total billed charges,Pays at 82.5% of total Billed charges,261.34,73,,209.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,250.6,70,,200.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.7,19.19,,54.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179,50,,143.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.7,295.35,
ELBOW LT 3+VIEWS,20057027,CDM,320,RC,73140,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
FINGER LT 2+ VIEWS,20057029,CDM,320,RC,73620,HCPCS,Outpatient,,,427,427,,,,,,Other,Not Separately Reimbursable,352.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,352.28,82.5,,281.824,percent of total billed charges,Pays at 82.5% of total Billed charges,311.71,73,,249.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,298.9,70,,239.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.94,19.19,,65.552,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,213.5,50,,170.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.94,352.28,
FOOT LT 2VIEWS,20057030,CDM,320,RC,73630,HCPCS,Outpatient,,,439,439,,,,,,Other,Not Separately Reimbursable,362.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,362.18,82.5,,289.744,percent of total billed charges,Pays at 82.5% of total Billed charges,320.47,73,,256.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,307.3,70,,245.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.24,19.19,,67.392,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,219.5,50,,175.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.24,362.18,
FOOT LT 3+VIEWS,20057031,CDM,320,RC,73090,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
FOREARM LT 2VIEWS,20057032,CDM,320,RC,73120,HCPCS,Outpatient,,,464,464,,,,,,Other,Not Separately Reimbursable,382.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,382.8,82.5,,306.24,percent of total billed charges,Pays at 82.5% of total Billed charges,338.72,73,,270.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,324.8,70,,259.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.04,19.19,,71.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,232,50,,185.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.04,382.8,
HAND LT 2VIEWS,20057033,CDM,320,RC,73130,HCPCS,Outpatient,,,341,341,,,,,,Other,Not Separately Reimbursable,281.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,281.33,82.5,,225.064,percent of total billed charges,Pays at 82.5% of total Billed charges,248.93,73,,199.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,238.7,70,,190.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.44,19.19,,52.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.5,50,,136.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.44,281.33,
HAND LT 3+VIEWS COMPLETE,20057034,CDM,320,RC,73650,HCPCS,Outpatient,,,530,530,,,,,,Other,Not Separately Reimbursable,437.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,437.25,82.5,,349.8,percent of total billed charges,Pays at 82.5% of total Billed charges,386.9,73,,309.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371,70,,296.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,19.19,,81.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,265,50,,212,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,437.25,
HEEL/CALC LT 2+VIEWS,20057035,CDM,320,RC,73060,HCPCS,Outpatient,,,422,422,,,,,,Other,Not Separately Reimbursable,348.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,348.15,82.5,,278.52,percent of total billed charges,Pays at 82.5% of total Billed charges,308.06,73,,246.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,295.4,70,,236.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.98,19.19,,64.784,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,211,50,,168.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.98,348.15,
HUMERUS LT 2 VIEWS,20057038,CDM,320,RC,73100,HCPCS,Outpatient,,,433,433,,,,,,Other,Not Separately Reimbursable,357.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,357.23,82.5,,285.784,percent of total billed charges,Pays at 82.5% of total Billed charges,316.09,73,,252.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,303.1,70,,242.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.09,19.19,,66.472,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216.5,50,,173.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.09,357.23,
WRIST LT 2VIEWS,20057040,CDM,320,RC,73110,HCPCS,Outpatient,,,381,381,,,,,,Other,Not Separately Reimbursable,314.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,314.33,82.5,,251.464,percent of total billed charges,Pays at 82.5% of total Billed charges,278.13,73,,222.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,266.7,70,,213.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.11,19.19,,58.488,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,190.5,50,,152.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.11,314.33,
WRIST LT COMP 3,20057041,CDM,320,RC,73560,HCPCS,Outpatient,,,480,480,,,,,,Other,Not Separately Reimbursable,396,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,396,82.5,,316.8,percent of total billed charges,Pays at 82.5% of total Billed charges,350.4,73,,280.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,336,70,,268.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.11,19.19,,73.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,240,50,,192,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.11,396,
KNEE LT 1-2VIEWS,20057042,CDM,320,RC,73564,HCPCS,Outpatient,,,370,370,,,,,,Other,Not Separately Reimbursable,305.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,305.25,82.5,,244.2,percent of total billed charges,Pays at 82.5% of total Billed charges,270.1,73,,216.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,259,70,,207.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,19.19,,56.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,185,50,,148,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,305.25,
KNEE LT 4+VIEWS COMPLETE,20057043,CDM,320,RC,73562,HCPCS,Outpatient,,,570,570,,,,,,Other,Not Separately Reimbursable,470.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,470.25,82.5,,376.2,percent of total billed charges,Pays at 82.5% of total Billed charges,416.1,73,,332.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,399,70,,319.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.38,19.19,,87.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,285,50,,228,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.38,470.25,
KNEE/PAT LT 3VIEWS,20057044,CDM,320,RC,73592,HCPCS,Outpatient,,,462,462,,,,,,Other,Not Separately Reimbursable,381.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,381.15,82.5,,304.92,percent of total billed charges,Pays at 82.5% of total Billed charges,337.26,73,,269.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,323.4,70,,258.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.66,19.19,,70.928,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,231,50,,184.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.66,381.15,
LOWER EXT LT INFANT 2+VIEWS,20057045,CDM,320,RC,73010,HCPCS,Outpatient,,,399,399,,,,,,Other,Not Separately Reimbursable,329.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,329.18,82.5,,263.344,percent of total billed charges,Pays at 82.5% of total Billed charges,291.27,73,,233.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,279.3,70,,223.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.57,19.19,,61.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,199.5,50,,159.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.57,329.18,
SCAPULA LT COMP,20057050,CDM,320,RC,73030,HCPCS,Outpatient,,,577,577,,,,,,Other,Not Separately Reimbursable,476.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,476.03,82.5,,380.824,percent of total billed charges,Pays at 82.5% of total Billed charges,421.21,73,,336.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,403.9,70,,323.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110.73,19.19,,88.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,288.5,50,,230.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110.73,476.03,
SHOULDER LT 2+VIEWS COMPLETE,20057051,CDM,320,RC,73020,HCPCS,Outpatient,,,515,515,,,,,,Other,Not Separately Reimbursable,424.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,424.88,82.5,,339.904,percent of total billed charges,Pays at 82.5% of total Billed charges,375.95,73,,300.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,360.5,70,,288.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.83,19.19,,79.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,257.5,50,,206,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.83,424.88,
SHOULDER LT 1 VIEW,20057052,CDM,320,RC,70330,HCPCS,Outpatient,,,185,185,,,,,,Other,Not Separately Reimbursable,152.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,152.63,82.5,,122.104,percent of total billed charges,Pays at 82.5% of total Billed charges,135.05,73,,108.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,129.5,70,,103.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,19.19,,28.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.5,50,,74,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,152.63,
TEMPOROMAND.JOINT BILATERAL,20057055,CDM,320,RC,73590,HCPCS,Outpatient,,,625,625,,,,,,Other,Not Separately Reimbursable,88.07,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,88.07,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,456.25,73,,365,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,437.5,70,,350,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,119.94,19.19,,95.952,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,312.5,50,,250,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.07,456.25,
TIB/FIB LT 2 VIEWS,20057057,CDM,320,RC,73660,HCPCS,Outpatient,,,489,489,,,,,,Other,Not Separately Reimbursable,403.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,403.43,82.5,,322.744,percent of total billed charges,Pays at 82.5% of total Billed charges,356.97,73,,285.576,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,342.3,70,,273.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.84,19.19,,75.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,244.5,50,,195.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.84,403.43,
TOE LT 2+VIEWS,20057058,CDM,320,RC,71101,HCPCS,Outpatient,,,319,319,,,,,,Other,Not Separately Reimbursable,263.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,263.18,82.5,,210.544,percent of total billed charges,Pays at 82.5% of total Billed charges,232.87,73,,186.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,223.3,70,,178.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.22,19.19,,48.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,159.5,50,,127.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.22,263.18,
RIBS LT 3+VIEWS,20057061,CDM,320,RC,70100,HCPCS,Outpatient,,,700,700,,,,,,Other,Not Separately Reimbursable,577.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,577.5,82.5,,462,percent of total billed charges,Pays at 82.5% of total Billed charges,511,73,,408.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,490,70,,392,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,134.33,19.19,,107.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,350,50,,280,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,134.33,577.5,
MANDIBLE < 4 VIEWS LTD,20057062,CDM,320,RC,70110,HCPCS,Outpatient,,,416,416,,,,,,Other,Not Separately Reimbursable,54.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,303.68,73,,242.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,291.2,70,,232.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.83,19.19,,63.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,208,50,,166.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.84,303.68,
MANDIBLE COMP.4+VIEWS,20057063,CDM,320,RC,77080,HCPCS,Outpatient,,,474,474,,,,,,Other,Not Separately Reimbursable,65.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,346.02,73,,276.816,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,331.8,70,,265.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.96,19.19,,72.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,237,50,,189.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.43,346.02,
Scan to measure bone mineral density (BMD) at the spine and hip,20057066,CDM,320,RC,77002,HCPCS,Outpatient,,,342,342,,,,,,Other,Not Separately Reimbursable,325.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,325.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,249.66,73,,199.728,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,239.4,70,,191.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.63,19.19,,52.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,171,50,,136.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.63,325.58,
FLUOROSCOPIC GUIDANCE NEEDLE PLACEMENT,20057067,CDM,320,RC,71045,HCPCS,Outpatient,,,651,651,,,,,,Other,Not Separately Reimbursable,136.87,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,136.87,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,475.23,73,,380.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,455.7,70,,364.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124.93,19.19,,99.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,325.5,50,,260.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124.93,475.23,
Single view,20071045,CDM,324,RC,71046,HCPCS,Outpatient,,,335,335,,,,,,Other,Not Separately Reimbursable,49.83,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,49.83,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,244.55,73,,195.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,234.5,70,,187.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.29,19.19,,51.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,167.5,50,,134,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.83,244.55,
"2 views, front and back",20071046,CDM,324,RC,71047,HCPCS,Outpatient,,,438,438,,,,,,Other,Not Separately Reimbursable,64.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,64.17,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,319.74,73,,255.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,306.6,70,,245.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.05,19.19,,67.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,219,50,,175.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.17,319.74,
3 views,20071047,CDM,324,RC,71048,HCPCS,Outpatient,,,541,541,,,,,,Other,Not Separately Reimbursable,57.74,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,57.74,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,394.93,73,,315.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,378.7,70,,302.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.82,19.19,,83.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,270.5,50,,216.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.74,394.93,
4 or more views,20071048,CDM,324,RC,72082,HCPCS,Outpatient,,,644,644,,,,,,Other,Not Separately Reimbursable,59.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,59.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,470.12,73,,376.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,450.8,70,,360.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,123.58,19.19,,98.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,322,50,,257.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.6,470.12,
SPINE THORACOLUMBER (SCOLIOSIS)SERIES,20072082,CDM,320,RC,72275,HCPCS,Outpatient,,,324,324,,,,,,Other,Not Separately Reimbursable,77.36,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,77.36,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,236.52,73,,189.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,226.8,70,,181.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.18,19.19,,49.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,162,50,,129.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.18,236.52,
EPIDUROGRAM,20072275,CDM,320,RC,73501,HCPCS,Outpatient,,,167,167,,,,,,Other,Not Separately Reimbursable,137.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,137.78,82.5,,110.224,percent of total billed charges,Pays at 82.5% of total Billed charges,121.91,73,,97.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.9,70,,93.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,19.19,,25.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.5,50,,66.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,137.78,
HIP RT 1 VIEW,20073501,CDM,320,RC,73502,HCPCS,Outpatient,,,306,306,,,,,,Other,Not Separately Reimbursable,252.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,252.45,82.5,,201.96,percent of total billed charges,Pays at 82.5% of total Billed charges,223.38,73,,178.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.2,70,,171.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,19.19,,46.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153,50,,122.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,252.45,
RT HIP 2+ VIEWS,20073502,CDM,320,RC,73521,HCPCS,Outpatient,,,521,521,,,,,,Other,Not Separately Reimbursable,429.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,429.83,82.5,,343.864,percent of total billed charges,Pays at 82.5% of total Billed charges,380.33,73,,304.264,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,364.7,70,,291.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.98,19.19,,79.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,260.5,50,,208.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.98,429.83,
HIP BIL 2+VIEWS EACH SIDE,20073521,CDM,320,RC,73552,HCPCS,Outpatient,,,608,608,,,,,,Other,Not Separately Reimbursable,70.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,70.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,443.84,73,,355.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,425.6,70,,340.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.68,19.19,,93.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,304,50,,243.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.47,443.84,
FEMUR RT 2VIEWS,20073552,CDM,320,RC,73564,HCPCS,Outpatient,,,455,455,,,,,,Other,Not Separately Reimbursable,375.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,375.38,82.5,,300.304,percent of total billed charges,Pays at 82.5% of total Billed charges,332.15,73,,265.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,318.5,70,,254.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.31,19.19,,69.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,227.5,50,,182,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.31,375.38,
KNEE LT 4+VIEWS - WEIGHT BEARING,20073564,CDM,320,RC,73630,HCPCS,Outpatient,,,570,570,,,,,,Other,Not Separately Reimbursable,470.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,470.25,82.5,,376.2,percent of total billed charges,Pays at 82.5% of total Billed charges,416.1,73,,332.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,399,70,,319.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.38,19.19,,87.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,285,50,,228,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.38,470.25,
FOOT LT 3+VIEWS-WEIGHT BEARING,20073630,CDM,320,RC,74018,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
ABDOMEN 1 VIEW,20074018,CDM,320,RC,74019,HCPCS,Outpatient,,,386,386,,,,,,Other,Not Separately Reimbursable,54.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,54.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,281.78,73,,225.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,270.2,70,,216.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.07,19.19,,59.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,193,50,,154.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.84,281.78,
ABDOMEN 2 VIEWS,20074019,CDM,320,RC,74021,HCPCS,Outpatient,,,469,469,,,,,,Other,Not Separately Reimbursable,65.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,342.37,73,,273.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,328.3,70,,262.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90,19.19,,72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,234.5,50,,187.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.14,342.37,
ABDOMEN 3 VIEWS,20074021,CDM,320,RC,74300,HCPCS,Outpatient,,,552,552,,,,,,Other,Not Separately Reimbursable,65.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,402.96,73,,322.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,386.4,70,,309.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.93,19.19,,84.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,276,50,,220.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.14,402.96,
OPERATIVE CHOLIANGIOGRAM,20074300,CDM,320,RC,75809,HCPCS,Outpatient,,,773,773,,,,,,Other,Not Separately Reimbursable,81.81,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,81.81,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,564.29,73,,451.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,541.1,70,,432.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.34,19.19,,118.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,386.5,50,,309.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.81,564.29,
NONVASCULAR SHUNT XRAY,20075809,CDM,320,RC,76496,HCPCS,Outpatient,,,1815,1815,,,,,,Other,Not Separately Reimbursable,1497.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1497.38,82.5,,1197.904,percent of total billed charges,Pays at 82.5% of total Billed charges,1324.95,73,,1059.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1270.5,70,,1016.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,348.3,19.19,,278.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,907.5,50,,726,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,348.3,1497.38,
UNLISTED FLOUROSCOPIC PROCEDURE,20076496,CDM,320,RC,77001,HCPCS,Outpatient,,,350,350,,,,,,Other,Not Separately Reimbursable,288.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,288.75,82.5,,231,percent of total billed charges,Pays at 82.5% of total Billed charges,255.5,73,,204.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245,70,,196,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.17,19.19,,53.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,50,,140,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.17,288.75,
FLUOROSCOPIC GUID CEN VENOUS ACCESS,20077001,CDM,320,RC,77003,HCPCS,Outpatient,,,651,651,,,,,,Other,Not Separately Reimbursable,537.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,537.08,82.5,,429.664,percent of total billed charges,Pays at 82.5% of total Billed charges,475.23,73,,380.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,455.7,70,,364.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124.93,19.19,,99.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,325.5,50,,260.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124.93,537.08,
FLOUROGUIDE FOR SPINE INJECT,20077003,CDM,320,RC,73501,HCPCS,Outpatient,,,350,350,,,,,,Other,Not Separately Reimbursable,288.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,288.75,82.5,,231,percent of total billed charges,Pays at 82.5% of total Billed charges,255.5,73,,204.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245,70,,196,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.17,19.19,,53.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,50,,140,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.17,288.75,
HIP LT 1 VIEW,20077777,CDM,320,RC,73502,HCPCS,Outpatient,,,306,306,,,,,,Other,Not Separately Reimbursable,252.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,252.45,82.5,,201.96,percent of total billed charges,Pays at 82.5% of total Billed charges,223.38,73,,178.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.2,70,,171.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,19.19,,46.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153,50,,122.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,252.45,
LT HIP 2+ VIEWS,20077778,CDM,320,RC,73552,HCPCS,Outpatient,,,521,521,,,,,,Other,Not Separately Reimbursable,429.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,429.83,82.5,,343.864,percent of total billed charges,Pays at 82.5% of total Billed charges,380.33,73,,304.264,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,364.7,70,,291.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.98,19.19,,79.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,260.5,50,,208.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.98,429.83,
FEMUR LT 2VIEWS,20077779,CDM,320,RC,78806,HCPCS,Outpatient,,,455,455,,,,,,Other,Not Separately Reimbursable,375.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,375.38,82.5,,300.304,percent of total billed charges,Pays at 82.5% of total Billed charges,332.15,73,,265.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,318.5,70,,254.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.31,19.19,,69.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,227.5,50,,182,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.31,375.38,
NUCLEAR RADIO INFLAMMATION/INFECTION WHO,20078806,CDM,343,RC,73564,HCPCS,Outpatient,,,1773,1773,,,,,,Other,Not Separately Reimbursable,1462.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1462.73,82.5,,1170.184,percent of total billed charges,Pays at 82.5% of total Billed charges,1294.29,73,,1035.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1241.1,70,,992.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,340.24,19.19,,272.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,886.5,50,,709.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,340.24,1462.73,
KNEE RT 4 VIEWS - WEIGHT BEARING,20173564,CDM,320,RC,73630,HCPCS,Outpatient,,,570,570,,,,,,Other,Not Separately Reimbursable,470.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,470.25,82.5,,376.2,percent of total billed charges,Pays at 82.5% of total Billed charges,416.1,73,,332.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,399,70,,319.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.38,19.19,,87.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,285,50,,228,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.38,470.25,
FOOT RT 3+VIEWS-WEIGHT BEARING,20173630,CDM,320,RC,72190,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
PELVIS 3+VIEWS COMPLETE,20800002,CDM,320,RC,19081,HCPCS,Outpatient,,,533,533,,,,,,Other,Not Separately Reimbursable,70.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,70.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,389.09,73,,311.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,373.1,70,,298.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.28,19.19,,81.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,266.5,50,,213.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.47,389.09,
DIGITAL NEEDLE LOC R OR L,21019081,CDM,401,RC,19281,HCPCS,Outpatient,,,486,486,,,,,,Other,Not Separately Reimbursable,400.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,400.95,82.5,,320.76,percent of total billed charges,Pays at 82.5% of total Billed charges,354.78,73,,283.824,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,340.2,70,,272.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.26,19.19,,74.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,243,50,,194.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.26,400.95,
DIGITAL S/P CLIP PLAC RT,21050120,CDM,401,RC,19281,HCPCS,Outpatient,,,187,187,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,136.51,73,,109.208,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,130.9,70,,104.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.89,19.19,,28.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.5,50,,74.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.89,982.8,
DIGITAL S/P CLIP PLAC LT,21050121,CDM,401,RC,19081,HCPCS,Outpatient,,,187,187,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,136.51,73,,109.208,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,130.9,70,,104.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.89,19.19,,28.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.5,50,,74.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.89,982.8,
DIGITAL S/P CLIP PLAC,21050122,CDM,401,RC,76098,HCPCS,Outpatient,,,256,256,,,,,,Other,Not Separately Reimbursable,211.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,211.2,82.5,,168.96,percent of total billed charges,Pays at 82.5% of total Billed charges,186.88,73,,149.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.2,70,,143.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.13,19.19,,39.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128,50,,102.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.13,211.2,
DIGITAL SPECIMEN POST OP,21076098,CDM,320,RC,77065,HCPCS,Outpatient,,,196,196,,,,,,Other,Not Separately Reimbursable,44.79,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,44.79,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,143.08,73,,114.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.2,70,,109.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.61,19.19,,30.088,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,50,,78.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.61,143.08,
"MAMMOGRAPHY DIAG, INC CAD UNIL LEFT",21077065,CDM,401,RC,77066,HCPCS,Outpatient,,,310,310,,,,,,Other,Not Separately Reimbursable,255.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,255.75,82.5,,204.6,percent of total billed charges,Pays at 82.5% of total Billed charges,226.3,73,,181.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,217,70,,173.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,19.19,,47.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155,50,,124,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,255.75,
"Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral",21077066,CDM,401,RC,77067,HCPCS,Outpatient,,,375,375,,,,,,Other,Not Separately Reimbursable,309.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,309.38,82.5,,247.504,percent of total billed charges,Pays at 82.5% of total Billed charges,273.75,73,,219,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,262.5,70,,210,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.96,19.19,,57.568,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,187.5,50,,150,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.96,309.38,
Mammography of both breasts-2 or more views,21077067,CDM,403,RC,77065,HCPCS,Outpatient,,,343,343,,,,,,Other,Not Separately Reimbursable,282.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,282.98,82.5,,226.384,percent of total billed charges,Pays at 82.5% of total Billed charges,250.39,73,,200.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,240.1,70,,192.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.82,19.19,,52.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,171.5,50,,137.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.82,282.98,
"MAMMOGRAPHY DIAG, INC CAD UNIL RIGHT",21177065,CDM,401,RC,G0297,HCPCS,Outpatient,,,310,310,,,,,,Other,Not Separately Reimbursable,255.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,255.75,82.5,,204.6,percent of total billed charges,Pays at 82.5% of total Billed charges,226.3,73,,181.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,217,70,,173.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,19.19,,47.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155,50,,124,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.49,255.75,
CT LOW DOSE LUNG SCREENING,22000297,CDM,352,RC,73200,HCPCS,Outpatient,,,1450,1450,,,,,,Other,Not Separately Reimbursable,1196.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1196.25,82.5,,957,percent of total billed charges,Pays at 82.5% of total Billed charges,1058.5,73,,846.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1015,70,,812,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,278.26,19.19,,222.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,725,50,,580,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,278.26,1196.25,
CT UPPER EXT W/O CONTRAST,22050111,CDM,352,RC,73201,HCPCS,Outpatient,,,2343,2343,,,,,,Other,Not Separately Reimbursable,521.36,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,521.36,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1710.39,73,,1368.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1640.1,70,,1312.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,449.62,19.19,,359.696,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1171.5,50,,937.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,449.62,1710.39,
CT UPPER EXT. W CONTRAST,22050116,CDM,352,RC,73202,HCPCS,Outpatient,,,1931,1931,,,,,,Other,Not Separately Reimbursable,620.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,620.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1409.63,73,,1127.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1351.7,70,,1081.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,370.56,19.19,,296.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,965.5,50,,772.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,370.56,1409.63,
CT UPPER EXT W/WO CONTRAST,22050117,CDM,352,RC,73701,HCPCS,Outpatient,,,3687,3687,,,,,,Other,Not Separately Reimbursable,780.54,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,780.54,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2691.51,73,,2153.208,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2580.9,70,,2064.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,707.54,19.19,,566.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1843.5,50,,1474.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,707.54,2691.51,
CT LOWER EXT W CONTRAST,22050118,CDM,352,RC,73700,HCPCS,Outpatient,,,1664,1664,,,,,,Other,Not Separately Reimbursable,620.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,620.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1214.72,73,,971.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1164.8,70,,931.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,319.32,19.19,,255.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,832,50,,665.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,319.32,1214.72,
CT scan of leg without dye,22050119,CDM,352,RC,73702,HCPCS,Outpatient,,,1677,1677,,,,,,Other,Not Separately Reimbursable,521.36,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,521.36,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1224.21,73,,979.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1173.9,70,,939.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,321.82,19.19,,257.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,838.5,50,,670.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,321.82,1224.21,
CT LOWER EXT W/WO CONTRAST,22050121,CDM,352,RC,70486,HCPCS,Outpatient,,,2947,2947,,,,,,Other,Not Separately Reimbursable,780.54,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,780.54,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2151.31,73,,1721.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2062.9,70,,1650.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,565.53,19.19,,452.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1473.5,50,,1178.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,565.53,2151.31,
CT Scan of the face and jaw without dye,22050160,CDM,351,RC,70460,HCPCS,Outpatient,,,2184,2184,,,,,,Other,Not Separately Reimbursable,496.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,496.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1594.32,73,,1275.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1528.8,70,,1223.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,419.11,19.19,,335.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1092,50,,873.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,419.11,1594.32,
CT HEAD/BRAIN W/CONTRAST,22050161,CDM,351,RC,70450,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,595.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,595.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595.35,2406.08,
CT scan head or brain without dye,22050162,CDM,351,RC,70470,HCPCS,Outpatient,,,3069,3069,,,,,,Other,Not Separately Reimbursable,496.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,496.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2240.37,73,,1792.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2148.3,70,,1718.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,588.94,19.19,,471.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1534.5,50,,1227.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,496.69,2240.37,
CT HEAD/BRAIN W & W/O CONTRAST,22050163,CDM,351,RC,70487,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,2406.08,
CT SINUSES (FACE)W/CONTRAST,22050164,CDM,351,RC,70488,HCPCS,Outpatient,,,2540,2540,,,,,,Other,Not Separately Reimbursable,595.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,595.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1854.2,73,,1483.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1778,70,,1422.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,487.43,19.19,,389.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1270,50,,1016,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,487.43,1854.2,
CT SINUSES (FACE)W & W/O CONTRAST,22050165,CDM,351,RC,72125,HCPCS,Outpatient,,,2852,2852,,,,,,Other,Not Separately Reimbursable,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2081.96,73,,1665.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1996.4,70,,1597.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,547.3,19.19,,437.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1426,50,,1140.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,547.3,2081.96,
CT CERV.SPINE W/O CONTRAST,22050170,CDM,352,RC,72128,HCPCS,Outpatient,,,3064,3064,,,,,,Other,Not Separately Reimbursable,620.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,620.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2236.72,73,,1789.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2144.8,70,,1715.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,587.98,19.19,,470.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1532,50,,1225.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,587.98,2236.72,
CT T-SPINE W/O CONTRAST,22050173,CDM,352,RC,72131,HCPCS,Outpatient,,,3296,3296,,,,,,Other,Not Separately Reimbursable,620.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,620.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2406.08,73,,1924.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2307.2,70,,1845.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632.5,19.19,,506,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1648,50,,1318.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,620.99,2406.08,
CT scan of lower spine without dye,22050176,CDM,352,RC,72193,HCPCS,Outpatient,,,3039,3039,,,,,,Other,Not Separately Reimbursable,620.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,620.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2218.47,73,,1774.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2127.3,70,,1701.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,583.18,19.19,,466.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1519.5,50,,1215.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,583.18,2218.47,
"CT scan, pelvis, with contrast",22050179,CDM,352,RC,72192,HCPCS,Outpatient,,,2895,2895,,,,,,Other,Not Separately Reimbursable,718.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,718.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2113.35,73,,1690.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2026.5,70,,1621.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,555.55,19.19,,444.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1447.5,50,,1158,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,555.55,2113.35,
CT of pelvis without dye,22050180,CDM,352,RC,72194,HCPCS,Outpatient,,,2488,2488,,,,,,Other,Not Separately Reimbursable,620.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,620.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1816.24,73,,1452.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1741.6,70,,1393.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,477.45,19.19,,381.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1244,50,,995.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,477.45,1816.24,
CT PELVIS W W/O CONTRAST,22050181,CDM,352,RC,70480,HCPCS,Outpatient,,,3358,3358,,,,,,Other,Not Separately Reimbursable,889.75,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,889.75,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2451.34,73,,1961.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2350.6,70,,1880.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,644.4,19.19,,515.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1679,50,,1343.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,644.4,2451.34,
CT ORBIT (MASTOID) IAC W/O,22050182,CDM,351,RC,74160,HCPCS,Outpatient,,,2781,2781,,,,,,Other,Not Separately Reimbursable,496.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,496.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2030.13,73,,1624.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1946.7,70,,1557.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,533.67,19.19,,426.936,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1390.5,50,,1112.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,496.69,2030.13,
CT of abdomen with dye,22050187,CDM,352,RC,74150,HCPCS,Outpatient,,,2735,2735,,,,,,Other,Not Separately Reimbursable,718.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,718.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1996.55,73,,1597.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1914.5,70,,1531.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,524.85,19.19,,419.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1367.5,50,,1094,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,524.85,1996.55,
CT of abdomen without dye,22050188,CDM,352,RC,74170,HCPCS,Outpatient,,,2266,2266,,,,,,Other,Not Separately Reimbursable,595.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,595.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1654.18,73,,1323.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1586.2,70,,1268.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,434.85,19.19,,347.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1133,50,,906.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,434.85,1654.18,
CT of abdomen with and without dye,22050189,CDM,352,RC,71260,HCPCS,Outpatient,,,3028,3028,,,,,,Other,Not Separately Reimbursable,889.75,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,889.75,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2210.44,73,,1768.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2119.6,70,,1695.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,581.07,19.19,,464.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1514,50,,1211.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,581.07,2210.44,
CT scan of the thorax with dye,22050195,CDM,352,RC,71250,HCPCS,Outpatient,,,3760,3760,,,,,,Other,Not Separately Reimbursable,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2744.8,73,,2195.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2632,70,,2105.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,721.54,19.19,,577.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1880,50,,1504,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,721.54,2744.8,
CT scan of the thorax without dye,22050196,CDM,352,RC,71270,HCPCS,Outpatient,,,2858,2858,,,,,,Other,Not Separately Reimbursable,620.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,620.99,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2086.34,73,,1669.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2000.6,70,,1600.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,548.45,19.19,,438.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1429,50,,1143.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,548.45,2086.34,
CT THORAX W W/O CONTRAST,22050197,CDM,352,RC,74160,HCPCS,Outpatient,,,3605,3605,,,,,,Other,Not Separately Reimbursable,926.98,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,926.98,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2631.65,73,,2105.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2523.5,70,,2018.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,691.8,19.19,,553.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1802.5,50,,1442,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,691.8,2631.65,
CT of abdomen with dye,22050210,CDM,352,RC,70491,HCPCS,Outpatient,,,2735,2735,,,,,,Other,Not Separately Reimbursable,718.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,718.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1996.55,73,,1597.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1914.5,70,,1531.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,524.85,19.19,,419.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1367.5,50,,1094,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,524.85,1996.55,
CT scan of neck with dye,22050220,CDM,350,RC,70490,HCPCS,Outpatient,,,2781,2781,,,,,,Other,Not Separately Reimbursable,595.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,595.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2030.13,73,,1624.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1946.7,70,,1557.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,533.67,19.19,,426.936,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1390.5,50,,1112.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,533.67,2030.13,
CT NECK W/O CONTRAST,22050221,CDM,350,RC,70492,HCPCS,Outpatient,,,2585,2585,,,,,,Other,Not Separately Reimbursable,496.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,496.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1887.05,73,,1509.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1809.5,70,,1447.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,496.06,19.19,,396.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1292.5,50,,1034,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,496.06,1887.05,
CT NECK W W/O CONTRAST,22050222,CDM,350,RC,76380,HCPCS,Outpatient,,,3053,3053,,,,,,Other,Not Separately Reimbursable,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2228.69,73,,1782.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2137.1,70,,1709.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,585.87,19.19,,468.696,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1526.5,50,,1221.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,585.87,2228.69,
CT FOLLOW UP LTD,22050223,CDM,350,RC,70481,HCPCS,Outpatient,,,773,773,,,,,,Other,Not Separately Reimbursable,367.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,367.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,564.29,73,,451.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,541.1,70,,432.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.34,19.19,,118.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,386.5,50,,309.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.34,564.29,
CT ORBIT (MASTOIDS) IAC WITH,22050224,CDM,351,RC,70480,HCPCS,Outpatient,,,2997,2997,,,,,,Other,Not Separately Reimbursable,595.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,595.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2187.81,73,,1750.248,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2097.9,70,,1678.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,575.12,19.19,,460.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1498.5,50,,1198.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,575.12,2187.81,
CT ORBIT (MASTOID) W/O CONTRAST,22055556,CDM,351,RC,70482,HCPCS,Outpatient,,,2781,2781,,,,,,Other,Not Separately Reimbursable,496.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,496.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2030.13,73,,1624.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1946.7,70,,1557.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,533.67,19.19,,426.936,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1390.5,50,,1112.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,496.69,2030.13,
CT ORBIT (MASTOIDS) IAC W&W/O,22055557,CDM,351,RC,70480,HCPCS,Outpatient,,,3027,3027,,,,,,Other,Not Separately Reimbursable,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2209.71,73,,1767.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2118.9,70,,1695.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,580.88,19.19,,464.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1513.5,50,,1210.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,580.88,2209.71,
CT TEMPORAL BONES W/O CONTRAST,22070480,CDM,351,RC,70481,HCPCS,Outpatient,,,2184,2184,,,,,,Other,Not Separately Reimbursable,496.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,496.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1594.32,73,,1275.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1528.8,70,,1223.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,419.11,19.19,,335.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1092,50,,873.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,419.11,1594.32,
CT TEMPORAL BONES W/CON,22070481,CDM,351,RC,70496,HCPCS,Outpatient,,,2540,2540,,,,,,Other,Not Separately Reimbursable,595.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,595.35,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1854.2,73,,1483.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1778,70,,1422.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,487.43,19.19,,389.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1270,50,,1016,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,487.43,1854.2,
"CT ANGIOGRAPHY, HEAD",22070496,CDM,351,RC,70498,HCPCS,Outpatient,,,3067,3067,,,,,,Other,Not Separately Reimbursable,2530.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2530.28,82.5,,2024.224,percent of total billed charges,Pays at 82.5% of total Billed charges,2238.91,73,,1791.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2146.9,70,,1717.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,588.56,19.19,,470.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1533.5,50,,1226.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,588.56,2530.28,
"CT ANGIOGRAPHY, NECK",22070498,CDM,351,RC,71275,HCPCS,Outpatient,,,3067,3067,,,,,,Other,Not Separately Reimbursable,2530.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2530.28,82.5,,2024.224,percent of total billed charges,Pays at 82.5% of total Billed charges,2238.91,73,,1791.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2146.9,70,,1717.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,588.56,19.19,,470.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1533.5,50,,1226.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,588.56,2530.28,
Diagnostic Radiology (Diagnostic Imaging) Procedures of the Chest,22071275,CDM,352,RC,72126,HCPCS,Outpatient,,,3914,3914,,,,,,Other,Not Separately Reimbursable,3229.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3229.05,82.5,,2583.24,percent of total billed charges,Pays at 82.5% of total Billed charges,2857.22,73,,2285.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2739.8,70,,2191.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,751.1,19.19,,600.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1957,50,,1565.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,751.1,3229.05,
CT CERV.SPINE WITH CONTRAST,22072126,CDM,352,RC,72127,HCPCS,Outpatient,,,3064,3064,,,,,,Other,Not Separately Reimbursable,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2236.72,73,,1789.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2144.8,70,,1715.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,587.98,19.19,,470.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1532,50,,1225.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,587.98,2236.72,
CT CERV.SPINE WITH AND WITHOUT CONTRAST,22072127,CDM,352,RC,72129,HCPCS,Outpatient,,,3064,3064,,,,,,Other,Not Separately Reimbursable,926.98,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,926.98,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2236.72,73,,1789.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2144.8,70,,1715.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,587.98,19.19,,470.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1532,50,,1225.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,587.98,2236.72,
CT THORACIC SPINE WITH CONTRAST,22072130,CDM,352,RC,72132,HCPCS,Outpatient,,,3064,3064,,,,,,Other,Not Separately Reimbursable,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2236.72,73,,1789.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2144.8,70,,1715.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,587.98,19.19,,470.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1532,50,,1225.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,587.98,2236.72,
CT LUMBAR SPINE WITH CONTRAST,22072133,CDM,352,RC,74174,HCPCS,Outpatient,,,3064,3064,,,,,,Other,Not Separately Reimbursable,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2236.72,73,,1789.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2144.8,70,,1715.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,587.98,19.19,,470.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1532,50,,1225.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,587.98,2236.72,
CT ANGIO ABDOMEN AND PELVIS,22074174,CDM,352,RC,74176,HCPCS,Outpatient,,,2709,2709,,,,,,Other,Not Separately Reimbursable,2234.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2234.93,82.5,,1787.944,percent of total billed charges,Pays at 82.5% of total Billed charges,1977.57,73,,1582.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1896.3,70,,1517.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,519.86,19.19,,415.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1354.5,50,,1083.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,519.86,2234.93,
CT of abdomen and pelvis without dye,22074176,CDM,352,RC,74177,HCPCS,Outpatient,,,2709,2709,,,,,,Other,Not Separately Reimbursable,1216.34,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1216.34,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1977.57,73,,1582.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1896.3,70,,1517.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,519.86,19.19,,415.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1354.5,50,,1083.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,519.86,1977.57,
CT scan of abdomen and pelvis with contrast,22074177,CDM,352,RC,74178,HCPCS,Outpatient,,,3358,3358,,,,,,Other,Not Separately Reimbursable,1436.27,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1436.27,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2451.34,73,,1961.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2350.6,70,,1880.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,644.4,19.19,,515.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1679,50,,1343.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,644.4,2451.34,
"Computed tomography, abdomen and pelvis; without contrast material in one or both body regions, followed by contrast material(s) and further sections ",22074178,CDM,352,RC,75635,HCPCS,Outpatient,,,3739,3739,,,,,,Other,Not Separately Reimbursable,1779.5,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1779.5,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2729.47,73,,2183.576,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2617.3,70,,2093.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,717.51,19.19,,574.008,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1869.5,50,,1495.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,717.51,2729.47,
CT ANGIO AORTA WITH ILIOFEMORAL RUNOFF,22075635,CDM,352,RC,76376,HCPCS,Outpatient,,,3914,3914,,,,,,Other,Not Separately Reimbursable,3229.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3229.05,82.5,,2583.24,percent of total billed charges,Pays at 82.5% of total Billed charges,2857.22,73,,2285.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2739.8,70,,2191.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,751.1,19.19,,600.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1957,50,,1565.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,751.1,3229.05,
3D RENDERING & POSTPROCESSING,22076376,CDM,350,RC,Q9967,HCPCS,Outpatient,,,361,361,,,,,,Other,Not Separately Reimbursable,370.88,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,370.88,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,263.53,73,,210.824,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.7,70,,202.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.28,19.19,,55.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.5,50,,144.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.28,370.88,
CT LOCM 300-399 MG/ML IODINE; 100ML,22109967,CDM,255,RC,78013,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,165,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,165,82.5,,132,percent of total billed charges,Pays at 82.5% of total Billed charges,146,73,,116.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,70,,112,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,19.19,,30.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100,50,,80,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,165,
NM THYROID IMAGING,23078013,CDM,341,RC,78070,HCPCS,Outpatient,,,1262,1262,,,,,,Other,Not Separately Reimbursable,208.06,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,208.06,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,921.26,73,,737.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,883.4,70,,706.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,242.18,19.19,,193.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,631,50,,504.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,208.06,921.26,
NM PARATHYROID NUCLEAR IMAGING,23078070,CDM,341,RC,78195,HCPCS,Outpatient,,,1028,1028,,,,,,Other,Not Separately Reimbursable,190.73,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,190.73,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,750.44,73,,600.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,719.6,70,,575.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,197.27,19.19,,157.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,514,50,,411.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,190.73,750.44,
NM LYMPH SYSTEM IMAGING,23078195,CDM,341,RC,78199,HCPCS,Outpatient,,,1393,1393,,,,,,Other,Not Separately Reimbursable,428.27,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,428.27,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1016.89,73,,813.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,975.1,70,,780.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,267.32,19.19,,213.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,696.5,50,,557.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,267.32,1016.89,
NM BLOOD/LYMP NUCLEAR EXAM,23078199,CDM,341,RC,78205,HCPCS,Outpatient,,,561,561,,,,,,Other,Not Separately Reimbursable,462.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,462.83,82.5,,370.264,percent of total billed charges,Pays at 82.5% of total Billed charges,409.53,73,,327.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,392.7,70,,314.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.66,19.19,,86.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280.5,50,,224.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.66,462.83,
NM LIVER SPECT IMAGING,23078205,CDM,341,RC,78215,HCPCS,Outpatient,,,1607,1607,,,,,,Other,Not Separately Reimbursable,1325.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1325.78,82.5,,1060.624,percent of total billed charges,Pays at 82.5% of total Billed charges,1173.11,73,,938.488,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1124.9,70,,899.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,308.38,19.19,,246.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,803.5,50,,642.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,308.38,1325.78,
NM LIVER & SPLEEN IMAGING,23078215,CDM,341,RC,78216,HCPCS,Outpatient,,,1138,1138,,,,,,Other,Not Separately Reimbursable,307.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,307.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,830.74,73,,664.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,796.6,70,,637.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,218.38,19.19,,174.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,569,50,,455.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,218.38,830.74,
NM LIVER & SPLEEN IMAGE/FLOW,23078216,CDM,341,RC,78226,HCPCS,Outpatient,,,1250,1250,,,,,,Other,Not Separately Reimbursable,365.87,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,365.87,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,912.5,73,,730,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,875,70,,700,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,239.88,19.19,,191.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,625,50,,500,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,239.88,912.5,
NM HEPATOBILIARY IMAGING,23078226,CDM,341,RC,78227,HCPCS,Outpatient,,,954,954,,,,,,Other,Not Separately Reimbursable,384.49,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,384.49,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,696.42,73,,557.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,667.8,70,,534.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,183.07,19.19,,146.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,477,50,,381.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,183.07,696.42,
NM HEPATOBILIARY IMAGING WITH CCK,23078227,CDM,341,RC,78264,HCPCS,Outpatient,,,1306,1306,,,,,,Other,Not Separately Reimbursable,384.49,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,384.49,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,953.38,73,,762.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,914.2,70,,731.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,250.62,19.19,,200.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,653,50,,522.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,250.62,953.38,
NM GASTRIC EMPTYING STUDY,23078264,CDM,341,RC,78278,HCPCS,Outpatient,,,1597,1597,,,,,,Other,Not Separately Reimbursable,433.28,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,433.28,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1165.81,73,,932.648,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1117.9,70,,894.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,306.46,19.19,,245.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,798.5,50,,638.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,306.46,1165.81,
NM ACUTE GI BLOOD LOSS IMAGING,23078278,CDM,341,RC,78290,HCPCS,Outpatient,,,1112,1112,,,,,,Other,Not Separately Reimbursable,512.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,512.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,811.76,73,,649.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,778.4,70,,622.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,213.39,19.19,,170.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,556,50,,444.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,213.39,811.76,
NM MECKELES DIVERT EXAM,23078290,CDM,341,RC,78300,HCPCS,Outpatient,,,1684,1684,,,,,,Other,Not Separately Reimbursable,319.06,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,319.06,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1229.32,73,,983.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1178.8,70,,943.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,323.16,19.19,,258.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,842,50,,673.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,319.06,1229.32,
NM BONE IMAGING; LIMITED AREA,23078300,CDM,341,RC,78306,HCPCS,Outpatient,,,850,850,,,,,,Other,Not Separately Reimbursable,262.71,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,262.71,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,620.5,73,,496.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595,70,,476,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.12,19.19,,130.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,425,50,,340,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.12,620.5,
"A procedure most commonly ordered to detect areas of abnormal bone growth due to fractures, tumors, infection, or other bone issues",23078306,CDM,341,RC,78315,HCPCS,Outpatient,,,2343,2343,,,,,,Other,Not Separately Reimbursable,448.91,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,448.91,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1710.39,73,,1368.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1640.1,70,,1312.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,449.62,19.19,,359.696,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1171.5,50,,937.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,448.91,1710.39,
NM BONE IMAGING; 3 PHASE,23078315,CDM,341,RC,78320,HCPCS,Outpatient,,,2464,2464,,,,,,Other,Not Separately Reimbursable,501.73,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,501.73,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1798.72,73,,1438.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1724.8,70,,1379.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,472.84,19.19,,378.272,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1232,50,,985.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,472.84,1798.72,
NM BONE SPECT IMAGING,23078320,CDM,341,RC,78452,HCPCS,Outpatient,,,2340,2340,,,,,,Other,Not Separately Reimbursable,1930.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1930.5,82.5,,1544.4,percent of total billed charges,Pays at 82.5% of total Billed charges,1708.2,73,,1366.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1638,70,,1310.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,449.05,19.19,,359.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1170,50,,936,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,449.05,1930.5,
Image of the heart to assess perfusion,23078452,CDM,341,RC,78451,HCPCS,Outpatient,,,4029,4029,,,,,,Other,Not Separately Reimbursable,1236.97,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1236.97,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2941.17,73,,2352.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2820.3,70,,2256.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,773.17,19.19,,618.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2014.5,50,,1611.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,773.17,2941.17,
NM HEART IMAGE (3D); SINGLE,23078464,CDM,341,RC,78452,HCPCS,Outpatient,,,2774,2774,,,,,,Other,Not Separately Reimbursable,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,743.31,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2025.02,73,,1620.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1941.8,70,,1553.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,532.33,19.19,,425.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1387,50,,1109.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,532.33,2025.02,
Image of the heart to assess perfusion,23078465,CDM,341,RC,78472,HCPCS,Outpatient,,,4029,4029,,,,,,Other,Not Separately Reimbursable,1236.97,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1236.97,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2941.17,73,,2352.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2820.3,70,,2256.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,773.17,19.19,,618.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2014.5,50,,1611.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,773.17,2941.17,
"NM GATED HEART, PLANAR; SINGLE",23078472,CDM,341,RC,78473,HCPCS,Outpatient,,,1679,1679,,,,,,Other,Not Separately Reimbursable,579.73,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,579.73,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1225.67,73,,980.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1175.3,70,,940.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,322.2,19.19,,257.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,839.5,50,,671.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,322.2,1225.67,
"NM GATED HEART, MULTIPLE",23078473,CDM,341,RC,78453,HCPCS,Outpatient,,,2606,2606,,,,,,Other,Not Separately Reimbursable,866.09,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,866.09,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1902.38,73,,1521.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1824.2,70,,1459.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,500.09,19.19,,400.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1303,50,,1042.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,500.09,1902.38,
NM HEART WALL MOTION ADD-ON,23078478,CDM,341,RC,78454,HCPCS,Outpatient,,,2470,2470,,,,,,Other,Not Separately Reimbursable,249.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,249.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1803.1,73,,1442.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1729,70,,1383.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,473.99,19.19,,379.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1235,50,,988,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,249.1,1803.1,
NM HEART FUNCTION ADD-ON,23078480,CDM,341,RC,78601,HCPCS,Outpatient,,,3647,3647,,,,,,Other,Not Separately Reimbursable,496.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,496.69,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,2662.31,73,,2129.848,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2552.9,70,,2042.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,699.86,19.19,,559.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1823.5,50,,1458.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,496.69,2662.31,
NM BRAIN IMAGING; LTD W/ FLOW,23078601,CDM,341,RC,78707,HCPCS,Outpatient,,,2279,2279,,,,,,Other,Not Separately Reimbursable,356.3,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,356.3,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1663.67,73,,1330.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1595.3,70,,1276.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,437.34,19.19,,349.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1139.5,50,,911.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,356.3,1663.67,
NM KIDNEY FLOW/FUNCTION IMAGE,23078707,CDM,341,RC,78708,HCPCS,Outpatient,,,2311,2311,,,,,,Other,Not Separately Reimbursable,469.54,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,469.54,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1687.03,73,,1349.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1617.7,70,,1294.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,443.48,19.19,,354.784,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1155.5,50,,924.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,443.48,1687.03,
NM K FLOW/FUNCT IMAGE W/ DRUG,23078708,CDM,341,RC,78805,HCPCS,Outpatient,,,1772,1772,,,,,,Other,Not Separately Reimbursable,508.54,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,508.54,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1293.56,73,,1034.848,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1240.4,70,,992.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,340.05,19.19,,272.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,886,50,,708.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,340.05,1293.56,
NM WHITE BLOOD CELL STUDY LIMITED,23078805,CDM,341,RC,78806,HCPCS,Outpatient,,,561,561,,,,,,Other,Not Separately Reimbursable,462.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,462.83,82.5,,370.264,percent of total billed charges,Pays at 82.5% of total Billed charges,409.53,73,,327.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,392.7,70,,314.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.66,19.19,,86.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280.5,50,,224.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.66,462.83,
NM WHITE BLOOD CELL STUDY WHOLE BODY,23078806,CDM,341,RC,J2805,HCPCS,Outpatient,,,561,561,,,,,,Other,Not Separately Reimbursable,462.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,462.83,82.5,,370.264,percent of total billed charges,Pays at 82.5% of total Billed charges,409.53,73,,327.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,392.7,70,,314.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.66,19.19,,86.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280.5,50,,224.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.66,462.83,
NM SINCALIDE INJECTION,23102805,CDM,636,RC,A9500,HCPCS,Outpatient,,,416,416,,,,,,Other,Not Separately Reimbursable,343.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,343.2,82.5,,274.56,percent of total billed charges,Pays at 82.5% of total Billed charges,303.68,73,,242.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,291.2,70,,232.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.83,19.19,,63.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,208,50,,166.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.83,343.2,
NM TC99M SESTAMIBI,23109500,CDM,343,RC,A9502,HCPCS,Outpatient,,,571,571,,,,,,Other,Not Separately Reimbursable,471.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,471.08,82.5,,376.864,percent of total billed charges,Pays at 82.5% of total Billed charges,416.83,73,,333.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,399.7,70,,319.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.57,19.19,,87.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,285.5,50,,228.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.57,471.08,
NM TC99M TETROFOSMIN,23109502,CDM,343,RC,A9503,HCPCS,Outpatient,,,497,497,,,,,,Other,Not Separately Reimbursable,410.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,410.03,82.5,,328.024,percent of total billed charges,Pays at 82.5% of total Billed charges,362.81,73,,290.248,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,347.9,70,,278.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.37,19.19,,76.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,248.5,50,,198.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.37,410.03,
NM TC99M MEDRONATE,23109503,CDM,343,RC,A9561,HCPCS,Outpatient,,,191,191,,,,,,Other,Not Separately Reimbursable,157.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,157.58,82.5,,126.064,percent of total billed charges,Pays at 82.5% of total Billed charges,139.43,73,,111.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133.7,70,,106.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.65,19.19,,29.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.5,50,,76.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.65,157.58,
NM TC99M OXIDRONATE,23109504,CDM,343,RC,A9505,HCPCS,Outpatient,,,191,191,,,,,,Other,Not Separately Reimbursable,157.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,157.58,82.5,,126.064,percent of total billed charges,Pays at 82.5% of total Billed charges,139.43,73,,111.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133.7,70,,106.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.65,19.19,,29.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.5,50,,76.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.65,157.58,
NM TL201 THALLIUM,23109505,CDM,343,RC,A9510,HCPCS,Outpatient,,,282,282,,,,,,Other,Not Separately Reimbursable,232.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,232.65,82.5,,186.12,percent of total billed charges,Pays at 82.5% of total Billed charges,205.86,73,,164.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,197.4,70,,157.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.12,19.19,,43.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,141,50,,112.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.12,232.65,
NM TC99M DISOFENIN,23109510,CDM,343,RC,A9512,HCPCS,Outpatient,,,183,183,,,,,,Other,Not Separately Reimbursable,150.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,150.98,82.5,,120.784,percent of total billed charges,Pays at 82.5% of total Billed charges,133.59,73,,106.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.1,70,,102.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.12,19.19,,28.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.5,50,,73.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.12,150.98,
NM TC99M PERTECHNETATE,23109512,CDM,343,RC,A9516,HCPCS,Outpatient,,,27,27,,,,,,Other,Not Separately Reimbursable,22.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,22.28,82.5,,17.824,percent of total billed charges,Pays at 82.5% of total Billed charges,19.71,73,,15.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.9,70,,15.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,19.19,,4.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.5,50,,10.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,22.28,
"NM I123 IODIDE CAP, DX",23109516,CDM,343,RC,A9521,HCPCS,Outpatient,,,98,98,,,,,,Other,Not Separately Reimbursable,80.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,80.85,82.5,,64.68,percent of total billed charges,Pays at 82.5% of total Billed charges,71.54,73,,57.232,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.6,70,,54.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.81,19.19,,15.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,50,,39.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.81,80.85,
NM TC99M CERETEC,23109521,CDM,343,RC,A9537,HCPCS,Outpatient,,,3665,3665,,,,,,Other,Not Separately Reimbursable,3023.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3023.63,82.5,,2418.904,percent of total billed charges,Pays at 82.5% of total Billed charges,2675.45,73,,2140.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2565.5,70,,2052.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,703.31,19.19,,562.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1832.5,50,,1466,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,703.31,3023.63,
NM TC99M MEBROFENIN,23109537,CDM,343,RC,A9538,HCPCS,Outpatient,,,354,354,,,,,,Other,Not Separately Reimbursable,292.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,292.05,82.5,,233.64,percent of total billed charges,Pays at 82.5% of total Billed charges,258.42,73,,206.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,247.8,70,,198.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,19.19,,54.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177,50,,141.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,292.05,
NM TC99M PYROPHOSPHATE,23109538,CDM,343,RC,A9539,HCPCS,Outpatient,,,94,94,,,,,,Other,Not Separately Reimbursable,77.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,77.55,82.5,,62.04,percent of total billed charges,Pays at 82.5% of total Billed charges,68.62,73,,54.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.8,70,,52.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.04,19.19,,14.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47,50,,37.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.04,77.55,
NM TC99M PENTETATE,23109539,CDM,343,RC,A9540,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,72.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,72.6,82.5,,58.08,percent of total billed charges,Pays at 82.5% of total Billed charges,64.24,73,,51.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,70,,49.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,19.19,,13.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44,50,,35.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,72.6,
NM TC99M MMA,23109540,CDM,343,RC,A9541,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,72.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,72.6,82.5,,58.08,percent of total billed charges,Pays at 82.5% of total Billed charges,64.24,73,,51.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,70,,49.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,19.19,,13.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44,50,,35.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,72.6,
NM TC99M SULFUR COLLOID,23109541,CDM,343,RC,A9548,HCPCS,Outpatient,,,263,263,,,,,,Other,Not Separately Reimbursable,216.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,216.98,82.5,,173.584,percent of total billed charges,Pays at 82.5% of total Billed charges,191.99,73,,153.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,184.1,70,,147.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.47,19.19,,40.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,131.5,50,,105.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.47,216.98,
NM IN111 PENTETATE,23109548,CDM,343,RC,A9556,HCPCS,Outpatient,,,4097,4097,,,,,,Other,Not Separately Reimbursable,3380.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3380.03,82.5,,2704.024,percent of total billed charges,Pays at 82.5% of total Billed charges,2990.81,73,,2392.648,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2867.9,70,,2294.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,786.21,19.19,,628.968,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2048.5,50,,1638.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,786.21,3380.03,
NM GA67 GALLIUM,23109556,CDM,343,RC,A9560,HCPCS,Outpatient,,,93,93,,,,,,Other,Not Separately Reimbursable,76.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,76.73,82.5,,61.384,percent of total billed charges,Pays at 82.5% of total Billed charges,67.89,73,,54.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.1,70,,52.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.85,19.19,,14.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.5,50,,37.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.85,76.73,
NM TC99M LABELED RBC,23109560,CDM,343,RC,A9562,HCPCS,Outpatient,,,183,183,,,,,,Other,Not Separately Reimbursable,150.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,150.98,82.5,,120.784,percent of total billed charges,Pays at 82.5% of total Billed charges,133.59,73,,106.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.1,70,,102.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.12,19.19,,28.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.5,50,,73.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.12,150.98,
NM TC99M MERTIATIDE,23109562,CDM,343,RC,19083,HCPCS,Outpatient,,,465,465,,,,,,Other,Not Separately Reimbursable,383.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,383.63,82.5,,306.904,percent of total billed charges,Pays at 82.5% of total Billed charges,339.45,73,,271.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,325.5,70,,260.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.23,19.19,,71.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,232.5,50,,186,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.23,383.63,
US GUIDANCE BREAST BIOPSY,24019083,CDM,361,RC,19084,HCPCS,Outpatient,,,908,908,,,,,,Other,Not Separately Reimbursable,749.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,749.1,82.5,,599.28,percent of total billed charges,Pays at 82.5% of total Billed charges,662.84,73,,530.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,635.6,70,,508.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.25,19.19,,139.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,454,50,,363.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.25,749.1,
US NEEDLE PLACEMENT ADD ON,24019084,CDM,361,RC,19101,HCPCS,Outpatient,,,335,335,,,,,,Other,Not Separately Reimbursable,276.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,276.38,82.5,,221.104,percent of total billed charges,Pays at 82.5% of total Billed charges,244.55,73,,195.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,234.5,70,,187.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.29,19.19,,51.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,167.5,50,,134,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.29,276.38,
US BX BREAST PRECUT W/ IMAGE,24019101,CDM,361,RC,76815,HCPCS,Outpatient,,,803,803,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,586.19,73,,468.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,562.1,70,,449.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154.1,19.19,,123.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,401.5,50,,321.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154.1,1319.85,
Ultrasound of fetus with limited views,24056723,CDM,402,RC,93931,HCPCS,Outpatient,,,118,118,,,,,,Other,Not Separately Reimbursable,149.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,149.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,86.14,73,,68.912,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.6,70,,66.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,19.19,,18.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59,50,,47.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,149.47,
US UPPER EXT ARTERIAL UNILAT,24056755,CDM,921,RC,93930,HCPCS,Outpatient,,,385,385,,,,,,Other,Not Separately Reimbursable,292.95,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,292.95,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,281.05,73,,224.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,269.5,70,,215.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.88,19.19,,59.104,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,192.5,50,,154,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.88,292.95,
US UPPER EXT ARTERIAL BILAT,24056756,CDM,921,RC,76705,HCPCS,Outpatient,,,794,794,,,,,,Other,Not Separately Reimbursable,444.87,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,444.87,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,579.62,73,,463.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,555.8,70,,444.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,152.37,19.19,,121.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,397,50,,317.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,152.37,579.62,
A diagnostic procedure that allows a provider to see the organs and other structures in the abdomen,24056771,CDM,402,RC,76770,HCPCS,Outpatient,,,854,854,,,,,,Other,Not Separately Reimbursable,149.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,149.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,623.42,73,,498.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,597.8,70,,478.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.88,19.19,,131.104,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,427,50,,341.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.47,623.42,
Ultrasound of back wall of the abdomen with all areas viewed,24056804,CDM,402,RC,76870,HCPCS,Outpatient,,,1114,1114,,,,,,Other,Not Separately Reimbursable,207.33,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,207.33,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,813.22,73,,650.576,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,779.8,70,,623.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,213.78,19.19,,171.024,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,557,50,,445.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,207.33,813.22,
Ultrasound of the scrotum,24056806,CDM,402,RC,76775,HCPCS,Outpatient,,,716,716,,,,,,Other,Not Separately Reimbursable,161.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,161.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,522.68,73,,418.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,501.2,70,,400.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.4,19.19,,109.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,358,50,,286.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.4,522.68,
Ultrasound of back wall of the abdomen with limited areas viewed,24056812,CDM,402,RC,93926,HCPCS,Outpatient,,,515,515,,,,,,Other,Not Separately Reimbursable,149.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,149.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,375.95,73,,300.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,360.5,70,,288.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.83,19.19,,79.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,257.5,50,,206,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.83,375.95,
US LOWER EXT ARTERIAL UNILAT,24056813,CDM,921,RC,76856,HCPCS,Outpatient,,,692,692,,,,,,Other,Not Separately Reimbursable,280.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,280.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,505.16,73,,404.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,484.4,70,,387.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.79,19.19,,106.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,346,50,,276.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.79,505.16,
Complete ultrasound of the pelvis,24056820,CDM,402,RC,76700,HCPCS,Outpatient,,,850,850,,,,,,Other,Not Separately Reimbursable,161.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,161.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,620.5,73,,496.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,595,70,,476,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.12,19.19,,130.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,425,50,,340,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.03,620.5,
Ultrasound of abdomen with all areas scanned,24056846,CDM,402,RC,93970,HCPCS,Outpatient,,,1056,1056,,,,,,Other,Not Separately Reimbursable,207.33,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,207.33,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,770.88,73,,616.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,739.2,70,,591.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,202.65,19.19,,162.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,528,50,,422.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,202.65,770.88,
Complete bilateral study of the extremities,24056851,CDM,921,RC,76857,HCPCS,Outpatient,,,1826,1826,,,,,,Other,Not Separately Reimbursable,465,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,465,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1332.98,73,,1066.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1278.2,70,,1022.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,350.41,19.19,,280.328,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,913,50,,730.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,350.41,1332.98,
Limited ultrasound of the pelvis,24056852,CDM,402,RC,76816,HCPCS,Outpatient,,,572,572,,,,,,Other,Not Separately Reimbursable,111.23,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,111.23,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,417.56,73,,334.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,400.4,70,,320.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.77,19.19,,87.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,286,50,,228.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.77,417.56,
US OB FOLLOWUP,24056903,CDM,402,RC,76536,HCPCS,Outpatient,,,185,185,,,,,,Other,Not Separately Reimbursable,117.24,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,117.24,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,135.05,73,,108.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,129.5,70,,103.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,19.19,,28.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.5,50,,74,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,135.05,
Ultrasound of head and neck,24056929,CDM,402,RC,76830,HCPCS,Outpatient,,,711,711,,,,,,Other,Not Separately Reimbursable,149.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,149.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,519.03,73,,415.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,497.7,70,,398.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,136.44,19.19,,109.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,355.5,50,,284.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,136.44,519.03,
Ultrasound of the pelvis through vagina,24056930,CDM,402,RC,76872,HCPCS,Outpatient,,,618,618,,,,,,Other,Not Separately Reimbursable,161.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,161.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,451.14,73,,360.912,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,432.6,70,,346.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,118.59,19.19,,94.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,309,50,,247.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,118.59,451.14,
Transrectal ultrasound,24056935,CDM,402,RC,93880,HCPCS,Outpatient,,,783,783,,,,,,Other,Not Separately Reimbursable,161.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,161.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,571.59,73,,457.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,548.1,70,,438.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,150.26,19.19,,120.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,391.5,50,,313.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,150.26,571.59,
Study of vessels on both sides of the head and neck,24056946,CDM,921,RC,93975,HCPCS,Outpatient,,,1033,1033,,,,,,Other,Not Separately Reimbursable,417.72,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,417.72,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,754.09,73,,603.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,723.1,70,,578.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,198.23,19.19,,158.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,516.5,50,,413.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,198.23,754.09,
US PELVIC VESSELS,24056947,CDM,921,RC,93320,HCPCS,Outpatient,,,862,862,,,,,,Other,Not Separately Reimbursable,526.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,526.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,629.26,73,,503.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,603.4,70,,482.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165.42,19.19,,132.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,431,50,,344.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165.42,629.26,
Echo with doppler,24056950,CDM,483,RC,76604,HCPCS,Outpatient,,,610,610,,,,,,Other,Not Separately Reimbursable,183.68,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,183.68,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,445.3,73,,356.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,427,70,,341.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.06,19.19,,93.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,305,50,,244,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.06,445.3,
US CHEST,24056951,CDM,402,RC,93320,HCPCS,Outpatient,,,348,348,,,,,,Other,Not Separately Reimbursable,136.87,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,136.87,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,254.04,73,,203.232,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,243.6,70,,194.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.78,19.19,,53.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174,50,,139.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.78,254.04,
Echo with doppler,24056953,CDM,483,RC,93325,HCPCS,Outpatient,,,610,610,,,,,,Other,Not Separately Reimbursable,183.68,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,183.68,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,445.3,73,,356.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,427,70,,341.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.06,19.19,,93.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,305,50,,244,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.06,445.3,
US COLOR FLOW DOPP &INTERP,24056954,CDM,483,RC,93325,HCPCS,Outpatient,,,808,808,,,,,,Other,Not Separately Reimbursable,314.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,314.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,589.84,73,,471.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,565.6,70,,452.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.06,19.19,,124.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,404,50,,323.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.06,589.84,
US COLOR FLOW DOPPLER,24056955,CDM,483,RC,76800,HCPCS,Outpatient,,,808,808,,,,,,Other,Not Separately Reimbursable,314.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,314.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,589.84,73,,471.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,565.6,70,,452.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.06,19.19,,124.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,404,50,,323.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,155.06,589.84,
US SPINAL CANAL,24056979,CDM,402,RC,76818,HCPCS,Outpatient,,,954,954,,,,,,Other,Not Separately Reimbursable,149.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,149.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,696.42,73,,557.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,667.8,70,,534.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,183.07,19.19,,146.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,477,50,,381.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.47,696.42,
Fetal biophysical profile with non-stress test,24056987,CDM,402,RC,76815,HCPCS,Outpatient,,,1074,1074,,,,,,Other,Not Separately Reimbursable,170.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,170.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,784.02,73,,627.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,751.8,70,,601.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,206.1,19.19,,164.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,537,50,,429.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.1,784.02,
Ultrasound of fetus with limited views,24057011,CDM,402,RC,93971,HCPCS,Outpatient,,,118,118,,,,,,Other,Not Separately Reimbursable,149.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,149.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,86.14,73,,68.912,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.6,70,,66.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,19.19,,18.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59,50,,47.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,149.47,
One sided or limited bilateral study,24057013,CDM,921,RC,93925,HCPCS,Outpatient,,,668,668,,,,,,Other,Not Separately Reimbursable,310.53,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,310.53,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,487.64,73,,390.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,467.6,70,,374.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.19,19.19,,102.552,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,334,50,,267.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.19,487.64,
US BILAT LOWER EXT ART,24057014,CDM,921,RC,93971,HCPCS,Outpatient,,,1290,1290,,,,,,Other,Not Separately Reimbursable,419.74,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,419.74,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,941.7,73,,753.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,903,70,,722.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,247.55,19.19,,198.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,645,50,,516,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,247.55,941.7,
One sided or limited bilateral study,24057015,CDM,921,RC,93970,HCPCS,Outpatient,,,668,668,,,,,,Other,Not Separately Reimbursable,310.53,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,310.53,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,487.64,73,,390.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,467.6,70,,374.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.19,19.19,,102.552,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,334,50,,267.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.19,487.64,
Complete bilateral study of the extremities,24057016,CDM,921,RC,93321,HCPCS,Outpatient,,,913,913,,,,,,Other,Not Separately Reimbursable,465,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,465,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,666.49,73,,533.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,639.1,70,,511.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175.2,19.19,,140.16,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,456.5,50,,365.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175.2,666.49,
US F/U CARDIAC DOPPLER,24058000,CDM,483,RC,93308,HCPCS,Outpatient,,,263,263,,,,,,Other,Not Separately Reimbursable,120.27,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,120.27,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,191.99,73,,153.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,184.1,70,,147.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.47,19.19,,40.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,131.5,50,,105.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.47,191.99,
US ECHO DOPPLER LIMITED,24058001,CDM,483,RC,93325,HCPCS,Outpatient,,,263,263,,,,,,Other,Not Separately Reimbursable,207.33,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,207.33,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,191.99,73,,153.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,184.1,70,,147.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.47,19.19,,40.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,131.5,50,,105.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.47,207.33,
US F/U COLOR FLOW DOPPLER,24058002,CDM,483,RC,76801,HCPCS,Outpatient,,,263,263,,,,,,Other,Not Separately Reimbursable,314.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,314.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,191.99,73,,153.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,184.1,70,,147.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.47,19.19,,40.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,131.5,50,,105.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.47,314.02,
Abdominal ultrasound of pregnant uterus (less than 14 weeks) single or first fetus,24058003,CDM,402,RC,76802,HCPCS,Outpatient,,,991,991,,,,,,Other,Not Separately Reimbursable,220.91,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,220.91,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,723.43,73,,578.744,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,693.7,70,,554.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,190.17,19.19,,152.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,495.5,50,,396.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,190.17,723.43,
US COMPLETE (TWINS)< 14WEEKS,24058004,CDM,402,RC,76805,HCPCS,Outpatient,,,504,504,,,,,,Other,Not Separately Reimbursable,220.91,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,220.91,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,367.92,73,,294.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,352.8,70,,282.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.72,19.19,,77.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252,50,,201.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.72,367.92,
Abdominal ultrasound of pregnant uterus (greater or equal to 14 weeks 0 days) single or first fetus,24058005,CDM,402,RC,76810,HCPCS,Outpatient,,,994,994,,,,,,Other,Not Separately Reimbursable,220.91,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,220.91,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,725.62,73,,580.496,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,695.8,70,,556.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,190.75,19.19,,152.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,497,50,,397.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,190.75,725.62,
US COMPLETE TWINS>14WEEKS,24058006,CDM,402,RC,76817,HCPCS,Outpatient,,,857,857,,,,,,Other,Not Separately Reimbursable,220.91,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,220.91,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,625.61,73,,500.488,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,599.9,70,,479.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,164.46,19.19,,131.568,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,428.5,50,,342.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,164.46,625.61,
Transvaginal ultrasound of uterus,24058007,CDM,402,RC,75860,HCPCS,Outpatient,,,736,736,,,,,,Other,Not Separately Reimbursable,607.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,607.2,82.5,,485.76,percent of total billed charges,Pays at 82.5% of total Billed charges,537.28,73,,429.824,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,515.2,70,,412.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,141.24,19.19,,112.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,368,50,,294.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,141.24,607.2,
US VEIN NECK,24075860,CDM,320,RC,76506,HCPCS,Outpatient,,,1876,1876,,,,,,Other,Not Separately Reimbursable,1322.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1322.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1369.48,73,,1095.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1313.2,70,,1050.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,360,19.19,,288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,938,50,,750.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,360,1369.48,
US BRAIN,24076506,CDM,402,RC,76641,HCPCS,Outpatient,,,954,954,,,,,,Other,Not Separately Reimbursable,149.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,149.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,696.42,73,,557.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,667.8,70,,534.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,183.07,19.19,,146.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,477,50,,381.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.47,696.42,
"US BREAST, UNILATERAL; COMPLETE",24076641,CDM,402,RC,76642,HCPCS,Outpatient,,,697,697,,,,,,Other,Not Separately Reimbursable,111.23,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,111.23,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,508.81,73,,407.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,487.9,70,,390.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133.75,19.19,,107,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,348.5,50,,278.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.23,508.81,
Limited ultrasound of the breast,24076642,CDM,402,RC,76819,HCPCS,Outpatient,,,697,697,,,,,,Other,Not Separately Reimbursable,111.23,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,111.23,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,508.81,73,,407.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,487.9,70,,390.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133.75,19.19,,107,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,348.5,50,,278.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.23,508.81,
Fetal biophysical profile without non-stress test,24076819,CDM,402,RC,76881,HCPCS,Outpatient,,,818,818,,,,,,Other,Not Separately Reimbursable,674.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,674.85,82.5,,539.88,percent of total billed charges,Pays at 82.5% of total Billed charges,597.14,73,,477.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,572.6,70,,458.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,156.97,19.19,,125.576,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,409,50,,327.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,156.97,674.85,
US NON VASCULAR EXTREMITY,24076880,CDM,402,RC,76942,HCPCS,Outpatient,,,606,606,,,,,,Other,Not Separately Reimbursable,149.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,149.47,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,442.38,73,,353.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,424.2,70,,339.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.29,19.19,,93.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,303,50,,242.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.29,442.38,
US GUIDANCE CENTRAL LINE,24076942,CDM,402,RC,76942,HCPCS,Outpatient,,,789,789,,,,,,Other,Not Separately Reimbursable,161.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,161.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,575.97,73,,460.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,552.3,70,,441.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.41,19.19,,121.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,394.5,50,,315.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.41,575.97,
US GUIDANCE INTRAOPERATIVE,24076998,CDM,402,RC,93306,HCPCS,Outpatient,,,789,789,,,,,,Other,Not Separately Reimbursable,161.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,161.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,575.97,73,,460.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,552.3,70,,441.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.41,19.19,,121.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,394.5,50,,315.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.41,575.97,
"Ultrasound examination of heart including color-depicted blood flow rate, direction, and valve function",24093306,CDM,480,RC,93882,HCPCS,Outpatient,,,923,923,,,,,,Other,Not Separately Reimbursable,761.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,761.48,82.5,,609.184,percent of total billed charges,Pays at 82.5% of total Billed charges,673.79,73,,539.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,646.1,70,,516.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177.12,19.19,,141.696,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,461.5,50,,369.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177.12,761.48,
US CAROTID SCREEN OR LIMITED,24093882,CDM,921,RC,93922,HCPCS,Outpatient,,,359,359,,,,,,Other,Not Separately Reimbursable,276.79,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,276.79,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,262.07,73,,209.656,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,251.3,70,,201.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.89,19.19,,55.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.5,50,,143.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.89,276.79,
Limited bilateral noninvasive physiologic studies of upper or lower extremity arteries,24093922,CDM,921,RC,93970,HCPCS,Outpatient,,,298,298,,,,,,Other,Not Separately Reimbursable,131.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,131.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,217.54,73,,174.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,208.6,70,,166.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.19,19.19,,45.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149,50,,119.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.19,217.54,
Complete bilateral study of the extremities,24093970,CDM,921,RC,93975,HCPCS,Outpatient,,,1826,1826,,,,,,Other,Not Separately Reimbursable,465,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,465,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1332.98,73,,1066.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1278.2,70,,1022.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,350.41,19.19,,280.328,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,913,50,,730.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,350.41,1332.98,
US ART&VEN ABD,24093975,CDM,921,RC,93990,HCPCS,Outpatient,,,503,503,,,,,,Other,Not Separately Reimbursable,526.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,526.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,367.19,73,,293.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,352.1,70,,281.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.53,19.19,,77.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,251.5,50,,201.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.53,526.43,
US DOPPLER FLOW TESTING,24093990,CDM,921,RC,,,Outpatient,,,258,258,,,,,,Other,Not Separately Reimbursable,280.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,280.32,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,188.34,73,,150.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.6,70,,144.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.51,19.19,,39.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,129,50,,103.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.51,280.32,
ABILIFY(ARIPIPRAZOLE)TAB:10 MG,25100005,CDM,250,RC,,,Outpatient,,,39,39,,,,,,Other,Not Separately Reimbursable,32.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,32.18,82.5,,25.744,percent of total billed charges,Pays at 82.5% of total Billed charges,28.47,73,,22.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.3,70,,21.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,19.19,,5.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.5,50,,15.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,32.18,
TRENTAL(PENTOXIFYLLINE)TAB:400MG,25100010,CDM,250,RC,J2440,HCPCS,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
PAPAVERINE INJ:60 MG,25100015,CDM,250,RC,,,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,9.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.9,82.5,,7.92,percent of total billed charges,Pays at 82.5% of total Billed charges,8.76,73,,7.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.4,70,,6.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,19.19,,1.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6,50,,4.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,9.9,
MILK OF MAGNESIA: 30ML,25100020,CDM,250,RC,J2505,HCPCS,Outpatient,,,17,17,,,,,,Other,Not Separately Reimbursable,14.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.03,82.5,,11.224,percent of total billed charges,Pays at 82.5% of total Billed charges,12.41,73,,9.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,70,,9.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.26,19.19,,2.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.5,50,,6.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.26,14.03,
NEULASTA(PEGFILGRASTIM)INJ:6 MG,25100025,CDM,636,RC,J1745,HCPCS,Outpatient,,,10829,10829,,,,,,Other,Not Separately Reimbursable,8933.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8933.93,82.5,,7147.144,percent of total billed charges,Pays at 82.5% of total Billed charges,7905.17,73,,6324.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7580.3,70,,6064.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2078.09,19.19,,1662.472,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5414.5,50,,4331.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2078.09,8933.93,
A biologic medication,25100030,CDM,636,RC,,,Outpatient,,,2302,2302,,,,,,Other,Not Separately Reimbursable,1899.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1899.15,82.5,,1519.32,percent of total billed charges,Pays at 82.5% of total Billed charges,1680.46,73,,1344.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1611.4,70,,1289.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,441.75,19.19,,353.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1151,50,,920.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,441.75,1899.15,
DIGOXIN(LANOXIN)TAB:0.125MG,25100035,CDM,250,RC,,,Outpatient,,,17,17,,,,,,Other,Not Separately Reimbursable,14.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.03,82.5,,11.224,percent of total billed charges,Pays at 82.5% of total Billed charges,12.41,73,,9.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,70,,9.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.26,19.19,,2.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.5,50,,6.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.26,14.03,
DIGOXIN(LANOXIN)TAB:0.25MG,25100040,CDM,250,RC,,,Outpatient,,,23,23,,,,,,Other,Not Separately Reimbursable,18.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,82.5,,15.184,percent of total billed charges,Pays at 82.5% of total Billed charges,16.79,73,,13.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.1,70,,12.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,19.19,,3.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.5,50,,9.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,18.98,
FUROSEMIDE(LASIX)TAB:40MG,25100045,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
FUROSEMIDE(LASIX)TAB:20MG,25100050,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
KCL(POTASSIUM CL)TAB:8MEQ,25100055,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
POTASSIUM CL(KCl)TAB:10MEQ,25100060,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ISOSORBIDE(ISORDIL)TAB:20MG,25100070,CDM,250,RC,J0881,HCPCS,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
ARANESP(DARBEPOETIN)INJ:1 MCG,25100075,CDM,636,RC,,,Outpatient,,,73,73,,,,,,Other,Not Separately Reimbursable,60.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,60.23,82.5,,48.184,percent of total billed charges,Pays at 82.5% of total Billed charges,53.29,73,,42.632,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.1,70,,40.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.01,19.19,,11.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.5,50,,29.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.01,60.23,
DOCUSATE SODIUM(COLACE)CAP:100 MG,25100110,CDM,250,RC,G8598,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ASPIRIN TAB:325MG,25100115,CDM,250,RC,G8598,HCPCS,Outpatient,,,2,2,,,,,,Other,Not Separately Reimbursable,1.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1.65,82.5,,1.32,percent of total billed charges,Pays at 82.5% of total Billed charges,1.46,73,,1.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.4,70,,1.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.38,19.19,,0.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1,50,,0.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.38,1.65,
ASPIRIN EC(ECOTRIN)TAB:325MG,25100120,CDM,250,RC,Q9968,HCPCS,Outpatient,,,2,2,,,,,,Other,Not Separately Reimbursable,1.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1.65,82.5,,1.32,percent of total billed charges,Pays at 82.5% of total Billed charges,1.46,73,,1.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.4,70,,1.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.38,19.19,,0.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1,50,,0.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.38,1.65,
LYMPHAZURIN BLUE 5 ML INJ,25100125,CDM,250,RC,,,Outpatient,,,775,775,,,,,,Other,Not Separately Reimbursable,639.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,639.38,82.5,,511.504,percent of total billed charges,Pays at 82.5% of total Billed charges,565.75,73,,452.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,542.5,70,,434,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.72,19.19,,118.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,387.5,50,,310,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.72,639.38,
ISOPTIN(VERAPAMIL)TAB:80MG,25100130,CDM,250,RC,,,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
VERAPAMIL ER TAB:240MG,25100135,CDM,250,RC,,,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
CIPROFLOXACIN(CIPRO)TAB:500MG,25100140,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
TEMAZEPAM(RESTORIL)CAP:15MG,25100145,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
OSELTAMIVIR(TAMIFLU)CAP:75MG,25100160,CDM,250,RC,,,Outpatient,,,138,138,,,,,,Other,Not Separately Reimbursable,113.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,113.85,82.5,,91.08,percent of total billed charges,Pays at 82.5% of total Billed charges,100.74,73,,80.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.6,70,,77.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.48,19.19,,21.184,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69,50,,55.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.48,113.85,
OSELTAMIVIR(TAMIFLU)CAP:45MG,25100161,CDM,250,RC,,,Outpatient,,,127,127,,,,,,Other,Not Separately Reimbursable,104.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,104.78,82.5,,83.824,percent of total billed charges,Pays at 82.5% of total Billed charges,92.71,73,,74.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.9,70,,71.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.37,19.19,,19.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.5,50,,50.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.37,104.78,
OSELTAMIVIR(TAMIFLU)CAP:30MG,25100162,CDM,250,RC,,,Outpatient,,,127,127,,,,,,Other,Not Separately Reimbursable,104.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,104.78,82.5,,83.824,percent of total billed charges,Pays at 82.5% of total Billed charges,92.71,73,,74.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.9,70,,71.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.37,19.19,,19.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.5,50,,50.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.37,104.78,
ALPRAZolam(XANAX)TAB:0.25MG,25100175,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ALPRAZolam(XANAX)TAB:0.5MG,25100180,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
PROCARDIA(NIFEDPINE)CAP:10MG,25100190,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
HYDROCORTISONE CR 30GM:1%,25100195,CDM,250,RC,,,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,15.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,15.68,82.5,,12.544,percent of total billed charges,Pays at 82.5% of total Billed charges,13.87,73,,11.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.3,70,,10.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,19.19,,2.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.5,50,,7.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,15.68,
LISINOPRIL(ZESTRIL)TAB:10MG,25100200,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
LISINOPRIL(ZESTRIL)TAB:20MG,25100201,CDM,250,RC,,,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,9.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.08,82.5,,7.264,percent of total billed charges,Pays at 82.5% of total Billed charges,8.03,73,,6.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.7,70,,6.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,19.19,,1.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.5,50,,4.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,9.08,
PHENERGAN(PROMETHAZINE)SUPP:25MG,25100205,CDM,250,RC,,,Outpatient,,,142,142,,,,,,Other,Not Separately Reimbursable,117.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,117.15,82.5,,93.72,percent of total billed charges,Pays at 82.5% of total Billed charges,103.66,73,,82.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.4,70,,79.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,19.19,,21.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,50,,56.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,117.15,
NEUTRA PHOS CAP,25100215,CDM,250,RC,,,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
PEG 3350(MIRALAX)PACKET: 17GRAM,25100220,CDM,250,RC,,,Outpatient,,,16,16,,,,,,Other,Not Separately Reimbursable,13.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13.2,82.5,,10.56,percent of total billed charges,Pays at 82.5% of total Billed charges,11.68,73,,9.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.2,70,,8.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,19.19,,2.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8,50,,6.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,13.2,
ZETIA (EZETIMIBE)TAB:10 MG,25100230,CDM,250,RC,,,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,14.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.85,82.5,,11.88,percent of total billed charges,Pays at 82.5% of total Billed charges,13.14,73,,10.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,70,,10.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,19.19,,2.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9,50,,7.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,14.85,
CAPTOPRIL(CAPOTEN)TAB:12.5MG,25100235,CDM,250,RC,,,Outpatient,,,16,16,,,,,,Other,Not Separately Reimbursable,13.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13.2,82.5,,10.56,percent of total billed charges,Pays at 82.5% of total Billed charges,11.68,73,,9.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.2,70,,8.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,19.19,,2.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8,50,,6.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,13.2,
PHENYTOIN(DILANTIN)CAP:100MG,25100240,CDM,250,RC,J2550,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
PROMETHAZINE(PHENERGAN)INJ:25MG,25100245,CDM,250,RC,J2300,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
NUBAIN(NALBUPHINE)INJ:10MG,25100250,CDM,250,RC,,,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,27.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.23,82.5,,21.784,percent of total billed charges,Pays at 82.5% of total Billed charges,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,27.23,
DIPHENOX/ATROPINE(LOMOTIL)TAB:,25100255,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
METOPROLOL(LOPRESSOR)TAB:50MG,25100260,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
LORazepam (ATIVAN)TAB : 0.5MG,25100270,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FENOFIBRATE(TRICOR)TAB:145MG,25100275,CDM,250,RC,,,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,38.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,38.78,82.5,,31.024,percent of total billed charges,Pays at 82.5% of total Billed charges,34.31,73,,27.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.9,70,,26.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,19.19,,7.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.5,50,,18.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,38.78,
GRANULEX(TRYPSIN/BALSAM) SPRAY:4 OZ,25100280,CDM,250,RC,,,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
METOPROLOL(LOPRESSOR)TAB:25MG,25100285,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DIASTAT RECTAL GEL: 2.5 MG,25100290,CDM,250,RC,,,Outpatient,,,525,525,,,,,,Other,Not Separately Reimbursable,433.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,433.13,82.5,,346.504,percent of total billed charges,Pays at 82.5% of total Billed charges,383.25,73,,306.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,367.5,70,,294,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.75,19.19,,80.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,262.5,50,,210,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.75,433.13,
ANTIVERT(MECLIZINE)TAB:25MG,25100300,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
CLONIDINE TAB:0.1MG,25100305,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CLONIDINE TAB:0.2MG,25100310,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
NTG(NITROGLYCERINE)TAB:0.4MG,25100315,CDM,250,RC,J3489,HCPCS,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,9.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.08,82.5,,7.264,percent of total billed charges,Pays at 82.5% of total Billed charges,8.03,73,,6.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.7,70,,6.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,19.19,,1.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.5,50,,4.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,9.08,
ZOLEDRONIC(RECLAST)INJ 5MG/100ML NS,25100320,CDM,636,RC,,,Outpatient,,,3480,3480,,,,,,Other,Not Separately Reimbursable,2871,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2871,82.5,,2296.8,percent of total billed charges,Pays at 82.5% of total Billed charges,2540.4,73,,2032.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2436,70,,1948.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,667.81,19.19,,534.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1740,50,,1392,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,667.81,2871,
MEMANTINE(NAMENDA)TAB:5MG,25100325,CDM,250,RC,,,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,47.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.03,82.5,,37.624,percent of total billed charges,Pays at 82.5% of total Billed charges,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,47.03,
ACCUCHECK ONLY (NO SLIDING SCALE),25100330,CDM,250,RC,,,Outpatient,,,16,16,,,,,,Other,Not Separately Reimbursable,13.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13.2,82.5,,10.56,percent of total billed charges,Pays at 82.5% of total Billed charges,11.68,73,,9.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.2,70,,8.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,19.19,,2.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8,50,,6.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,13.2,
SITAGLIPTIN(JANUVIA)TAB:50MG,25100335,CDM,250,RC,J1815,HCPCS,Outpatient,,,145,145,,,,,,Other,Not Separately Reimbursable,119.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,119.63,82.5,,95.704,percent of total billed charges,Pays at 82.5% of total Billed charges,105.85,73,,84.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.5,70,,81.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.83,19.19,,22.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.5,50,,58,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.83,119.63,
HUMULIN/NOVOLIN 70/30 INSULIN,25100340,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
NEOSPORIN(TRIPLE ANTIBIOTIC)OINT PKT,25100345,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CLINIMIX E 4.25 W/DEXTROSE 25%1000 ML,25100350,CDM,250,RC,,,Outpatient,,,250,250,,,,,,Other,Not Separately Reimbursable,206.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,206.25,82.5,,165,percent of total billed charges,Pays at 82.5% of total Billed charges,182.5,73,,146,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,70,,140,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,19.19,,38.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125,50,,100,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,206.25,
INTRALIPID 20% 250 ML,25100351,CDM,250,RC,,,Outpatient,,,250,250,,,,,,Other,Not Separately Reimbursable,206.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,206.25,82.5,,165,percent of total billed charges,Pays at 82.5% of total Billed charges,182.5,73,,146,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,70,,140,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,19.19,,38.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125,50,,100,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,206.25,
CLINIMIX E 5% W/DEXTROSE 25%1000 ML,25100352,CDM,250,RC,,,Outpatient,,,210,210,,,,,,Other,Not Separately Reimbursable,173.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,173.25,82.5,,138.6,percent of total billed charges,Pays at 82.5% of total Billed charges,153.3,73,,122.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,70,,117.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,19.19,,32.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,50,,84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,173.25,
CLINIMIX 5%/DEX 25% SOLN.,25100353,CDM,250,RC,J1815,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
HUMULIN NPH INJ : 5 UNITS,25100355,CDM,250,RC,,,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
THEOPHYLLINE(THEO-DUR)TAB:300 MG,25100360,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ALPRAZolam(XANAX)TAB:1MG,25100365,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENALAPRIL (VASOTEC)TAB:5MG,25100375,CDM,250,RC,,,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,9.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.08,82.5,,7.264,percent of total billed charges,Pays at 82.5% of total Billed charges,8.03,73,,6.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.7,70,,6.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,19.19,,1.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.5,50,,4.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,9.08,
VASOPRESSIN INJ:20UNITS/ML,25100400,CDM,250,RC,,,Outpatient,,,890,890,,,,,,Other,Not Separately Reimbursable,734.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,734.25,82.5,,587.4,percent of total billed charges,Pays at 82.5% of total Billed charges,649.7,73,,519.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,623,70,,498.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,19.19,,136.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,445,50,,356,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.79,734.25,
IBUPROFEN(MOTRIN)TAB:800MG,25100410,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
IBUPROFEN(MOTRIN)TAB:600MG,25100415,CDM,250,RC,J2785,HCPCS,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
LEXISCAN(REGADENOSON)INJ:0.4MG/5ML,25100430,CDM,636,RC,,,Outpatient,,,1643,1643,,,,,,Other,Not Separately Reimbursable,1355.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1355.48,82.5,,1084.384,percent of total billed charges,Pays at 82.5% of total Billed charges,1199.39,73,,959.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1150.1,70,,920.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,315.29,19.19,,252.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,821.5,50,,657.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,315.29,1355.48,
THEO-DUR(THEOPHYLLINE)TAB:200MG,25100440,CDM,250,RC,Q0163,HCPCS,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
diphenhydrAMINE(BENADRYL)CAP:25MG,25100445,CDM,250,RC,,,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
SANTYL(COLLAGENASE)OINT,25100455,CDM,250,RC,,,Outpatient,,,412,412,,,,,,Other,Not Separately Reimbursable,339.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,339.9,82.5,,271.92,percent of total billed charges,Pays at 82.5% of total Billed charges,300.76,73,,240.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,288.4,70,,230.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.06,19.19,,63.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,206,50,,164.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.06,339.9,
HALOPERIDOL(HALDOL)TAB:1 MG,25100460,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
LUGOL'S SOLN : 60ML,25100465,CDM,250,RC,,,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,7.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,7.43,82.5,,5.944,percent of total billed charges,Pays at 82.5% of total Billed charges,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,7.43,
hydrOXYzine(ATARAX)TAB:25MG,25100500,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
PENTASA(MESALAMINE)CR CAP:500 MG,25100505,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
ACETAM/CODEINE(TYLENOL/COD.)TAB:300/30MG,25100510,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
BISACODYL(DULCOLAX) TAB : 5MG,25100520,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
BISACODYL(DULCOLAX) SUPP:10 MG,25100525,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DILTIAZEM(CARDIZEM)TAB:30MG,25100535,CDM,250,RC,P9047,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ALBUMIN 25% 50 ML:12.5 GM,25100545,CDM,636,RC,,,Outpatient,,,270,270,,,,,,Other,Not Separately Reimbursable,222.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,222.75,82.5,,178.2,percent of total billed charges,Pays at 82.5% of total Billed charges,197.1,73,,157.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,189,70,,151.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.81,19.19,,41.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,135,50,,108,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.81,222.75,
CLINDAMYCIN(CLEOCIN)CAP:150MG,25100585,CDM,250,RC,,,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,9.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.9,82.5,,7.92,percent of total billed charges,Pays at 82.5% of total Billed charges,8.76,73,,7.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.4,70,,6.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,19.19,,1.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6,50,,4.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,9.9,
METOCLOPRAMIDE(REGLAN)TAB:5MG,25100595,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
PHENOBARBITAL TAB:32.4MG,25100615,CDM,250,RC,J2175,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
MEPERIDINE(DEMEROL)INJ:50MG,25100640,CDM,250,RC,,,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,31.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,31.35,82.5,,25.08,percent of total billed charges,Pays at 82.5% of total Billed charges,27.74,73,,22.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.6,70,,21.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,19.19,,5.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,50,,15.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,31.35,
COUMADIN (WARFARIN)TAB: 2 MG,25100660,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
WARFARIN(COUMADIN)TAB:2.5MG,25100665,CDM,250,RC,,,Outpatient,,,23,23,,,,,,Other,Not Separately Reimbursable,18.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,82.5,,15.184,percent of total billed charges,Pays at 82.5% of total Billed charges,16.79,73,,13.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.1,70,,12.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,19.19,,3.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.5,50,,9.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,18.98,
WARFARIN(COUMADIN)TAB:1MG,25100666,CDM,250,RC,,,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,14.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.85,82.5,,11.88,percent of total billed charges,Pays at 82.5% of total Billed charges,13.14,73,,10.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,70,,10.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,19.19,,2.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9,50,,7.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,14.85,
WARFARIN(COUMADIN)TAB:5MG,25100670,CDM,250,RC,,,Outpatient,,,24,24,,,,,,Other,Not Separately Reimbursable,19.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,19.8,82.5,,15.84,percent of total billed charges,Pays at 82.5% of total Billed charges,17.52,73,,14.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.8,70,,13.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.61,19.19,,3.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12,50,,9.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.61,19.8,
FLUOXETINE(PROZAC)CAP:20MG,25100740,CDM,250,RC,,,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,20.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,20.63,82.5,,16.504,percent of total billed charges,Pays at 82.5% of total Billed charges,18.25,73,,14.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,70,,14,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,19.19,,3.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,50,,10,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,20.63,
AMITRIPTYLINE(ELAVIL)TAB:25MG,25100750,CDM,250,RC,J0885,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
"EPOGEN INJ : 1,000 UNITS",25100760,CDM,636,RC,,,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
NIFEDIPINE XL(PROCARDIA XL)TAB:30MG,25100775,CDM,250,RC,,,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
CIPROFLOXACIN(CIPRO)TAB:250MG,25100805,CDM,250,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
MetroNIDAZOLE(FLAGYL)TAB:250MG,25100815,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
MOXIFLOXACIN (AVELOX) TAB: 400 MG,25100820,CDM,250,RC,,,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
FLUCONAZOLE(DIFLUCAN)TAB:100MG,25100825,CDM,250,RC,,,Outpatient,,,79,79,,,,,,Other,Not Separately Reimbursable,65.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,65.18,82.5,,52.144,percent of total billed charges,Pays at 82.5% of total Billed charges,57.67,73,,46.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.3,70,,44.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,19.19,,12.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.5,50,,31.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,65.18,
GLYBURIDE(DIABETA)TAB:5MG,25100840,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
LORazepam(ATIVAN)TAB:1MG,25100850,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FERO-FOLIC TABLET:500MG,25100865,CDM,250,RC,,,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
ACETAMINOPHEN(TYLENOL)SUPP:650MG,25100870,CDM,250,RC,,,Outpatient,,,7,7,,,,,,Other,Not Separately Reimbursable,5.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5.78,82.5,,4.624,percent of total billed charges,Pays at 82.5% of total Billed charges,5.11,73,,4.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.9,70,,3.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,19.19,,1.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,50,,2.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,5.78,
MORPHINE ER(MS CONTIN)TAB:30MG,25100875,CDM,250,RC,J2550,HCPCS,Outpatient,,,17,17,,,,,,Other,Not Separately Reimbursable,14.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.03,82.5,,11.224,percent of total billed charges,Pays at 82.5% of total Billed charges,12.41,73,,9.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,70,,9.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.26,19.19,,2.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.5,50,,6.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.26,14.03,
PHENERGAN(PROMETHAZINE)INJ.50MG,25100880,CDM,250,RC,,,Outpatient,,,23,23,,,,,,Other,Not Separately Reimbursable,18.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,82.5,,15.184,percent of total billed charges,Pays at 82.5% of total Billed charges,16.79,73,,13.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.1,70,,12.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,19.19,,3.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.5,50,,9.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,18.98,
CHLORASEPTIC SPRAY 6OZ:,25100895,CDM,250,RC,,,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,14.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.85,82.5,,11.88,percent of total billed charges,Pays at 82.5% of total Billed charges,13.14,73,,10.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,70,,10.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,19.19,,2.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9,50,,7.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,14.85,
ZOVIRAX OINT : 5% 15GM,25100910,CDM,250,RC,J2175,HCPCS,Outpatient,,,97,97,,,,,,Other,Not Separately Reimbursable,80.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,80.03,82.5,,64.024,percent of total billed charges,Pays at 82.5% of total Billed charges,70.81,73,,56.648,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.9,70,,54.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.61,19.19,,14.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.5,50,,38.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.61,80.03,
MEPERIDINE(DEMEROL)INJ:25MG,25100940,CDM,250,RC,J2175,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
MEPERIDINE(DEMEROL)INJ:75MG,25100945,CDM,250,RC,,,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,31.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,31.35,82.5,,25.08,percent of total billed charges,Pays at 82.5% of total Billed charges,27.74,73,,22.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.6,70,,21.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,19.19,,5.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,50,,15.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,31.35,
ECONOPRED PLUS 1% 5 ML,25100955,CDM,250,RC,J3243,HCPCS,Outpatient,,,97,97,,,,,,Other,Not Separately Reimbursable,80.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,80.03,82.5,,64.024,percent of total billed charges,Pays at 82.5% of total Billed charges,70.81,73,,56.648,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.9,70,,54.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.61,19.19,,14.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.5,50,,38.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.61,80.03,
TYGACIL(TIGECYCLINE) INJ:50 MG,25100960,CDM,250,RC,J3410,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately Reimbursable,207.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,207.9,82.5,,166.32,percent of total billed charges,Pays at 82.5% of total Billed charges,183.96,73,,147.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.4,70,,141.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.36,19.19,,38.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126,50,,100.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.36,207.9,
hydrOXYzine(VISTARIL)INJ:50MG,25100995,CDM,250,RC,J2270,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
MORPHINE SULFATE INJ: 2MG,25101005,CDM,636,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
HYDROCODONE 10MG/APAP 325MG(NORCO),25101010,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
PANTOPRAZOLE(PROTONIX)TAB:40MG,25101015,CDM,250,RC,,,Outpatient,,,148,148,,,,,,Other,Not Separately Reimbursable,122.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.1,82.5,,97.68,percent of total billed charges,Pays at 82.5% of total Billed charges,108.04,73,,86.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.6,70,,82.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.4,19.19,,22.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74,50,,59.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.4,122.1,
glipiZIDE(GLUCOTROL)TAB:5MG,25101025,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DIAZEPAM(VALIUM)TAB:2MG,25101065,CDM,250,RC,,,Outpatient,,,7,7,,,,,,Other,Not Separately Reimbursable,5.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5.78,82.5,,4.624,percent of total billed charges,Pays at 82.5% of total Billed charges,5.11,73,,4.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.9,70,,3.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,19.19,,1.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,50,,2.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,5.78,
DIAZEPAM(VALIUM)TAB:5MG,25101070,CDM,250,RC,,,Outpatient,,,7,7,,,,,,Other,Not Separately Reimbursable,5.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5.78,82.5,,4.624,percent of total billed charges,Pays at 82.5% of total Billed charges,5.11,73,,4.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.9,70,,3.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,19.19,,1.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,50,,2.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,5.78,
VALIUM(DIAZEPAM)TAB:10MG,25101075,CDM,250,RC,J3360,HCPCS,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
DIAZEPAM(VALIUM)2ML INJ:10MG,25101085,CDM,250,RC,,,Outpatient,,,248,248,,,,,,Other,Not Separately Reimbursable,204.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,204.6,82.5,,163.68,percent of total billed charges,Pays at 82.5% of total Billed charges,181.04,73,,144.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,173.6,70,,138.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.59,19.19,,38.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124,50,,99.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.59,204.6,
CARBAMAZINE(TEGretol)TAB:200MG,25101090,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
METHOCARBAMOL(ROBAXIN)TAB:750MG,25101100,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
NTG(NITROGLYCERIN)TRANSDERM 0.1MG/HR,25101105,CDM,250,RC,,,Outpatient,,,26,26,,,,,,Other,Not Separately Reimbursable,21.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,21.45,82.5,,17.16,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,73,,15.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.2,70,,14.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,19.19,,3.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13,50,,10.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,21.45,
SILVER SULFADIAZENE 1% CREAM:25GM,25101115,CDM,250,RC,,,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
SYNTHROID(LEVOTHYROXINE)TAB:0.1,25101120,CDM,250,RC,,,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
ISOPTIN SR (VERAPAMIL) TAB:120 MG,25101125,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
PROMETHAZINE(PHENERGAN)SUPP:12.5MG,25101145,CDM,250,RC,,,Outpatient,,,142,142,,,,,,Other,Not Separately Reimbursable,117.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,117.15,82.5,,93.72,percent of total billed charges,Pays at 82.5% of total Billed charges,103.66,73,,82.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,99.4,70,,79.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,19.19,,21.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,50,,56.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.25,117.15,
OXYCODONE/APAP(PERCOCET)TAB:5/325 MG,25101170,CDM,250,RC,J3535,HCPCS,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
PROVENTIL (ALBUTEROL) INHALER: 17GM,25101175,CDM,250,RC,,,Outpatient,,,109,109,,,,,,Other,Not Separately Reimbursable,89.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,89.93,82.5,,71.944,percent of total billed charges,Pays at 82.5% of total Billed charges,79.57,73,,63.656,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.3,70,,61.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.92,19.19,,16.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.5,50,,43.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.92,89.93,
LABETALOL(NORMODYNE) TAB : 100MG,25101190,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
PROMETHAZINE(PHENERGAN)TAB:25MG,25101210,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ACCUZYME DEBRIDING OINTMENT,25101225,CDM,250,RC,,,Outpatient,,,171,171,,,,,,Other,Not Separately Reimbursable,141.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,141.08,82.5,,112.864,percent of total billed charges,Pays at 82.5% of total Billed charges,124.83,73,,99.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,119.7,70,,95.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.81,19.19,,26.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85.5,50,,68.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.81,141.08,
ACETAMINOPHEN (TYLENOL)SUPP: 325 MG,25101230,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ALLOPURINOL(ZYLOPRIM)TAB:300MG,25101245,CDM,250,RC,G8598,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ASPIRIN TAB:81MG CHEWABLE,25101250,CDM,250,RC,,,Outpatient,,,2,2,,,,,,Other,Not Separately Reimbursable,1.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1.65,82.5,,1.32,percent of total billed charges,Pays at 82.5% of total Billed charges,1.46,73,,1.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.4,70,,1.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.38,19.19,,0.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1,50,,0.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.38,1.65,
HYDROCHLOROTHIAZIDE TAB:25 MG,25101265,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
HYDROCHLOROTHIAZIDE CAP:12.5MG,25101266,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
GLYCOPYRROLATE(ROBINUL)0.2MG/ML:1ML,25101285,CDM,250,RC,,,Outpatient,,,163,163,,,,,,Other,Not Separately Reimbursable,134.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,134.48,82.5,,107.584,percent of total billed charges,Pays at 82.5% of total Billed charges,118.99,73,,95.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,114.1,70,,91.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.28,19.19,,25.024,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.5,50,,65.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.28,134.48,
CYCLOBENZAPRINE(FLEXERIL)TAB:10MG,25101295,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
FUROSEMIDE(LASIX)TAB:80MG,25101310,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
KCL(POTASSIUM CL)20% ORAL SOL:40MEQ/15ML,25101315,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
MEPHYTON(PHYTONADIONE)TAB: 5 MG,25101320,CDM,250,RC,J3430,HCPCS,Outpatient,,,34,34,,,,,,Other,Not Separately Reimbursable,28.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.05,82.5,,22.44,percent of total billed charges,Pays at 82.5% of total Billed charges,24.82,73,,19.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,70,,19.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,19.19,,5.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17,50,,13.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,28.05,
AQUAMEPHYTON(PHYTONADIONE)INJ:1MG,25101322,CDM,636,RC,J3430,HCPCS,Outpatient,,,8,8,,,,,,Other,Not Separately Reimbursable,6.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6.6,82.5,,5.28,percent of total billed charges,Pays at 82.5% of total Billed charges,5.84,73,,4.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.6,70,,4.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,19.19,,1.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4,50,,3.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,6.6,
PHYTONADIONE(AQUAMEPHYTON)INJ:10 MG,25101323,CDM,636,RC,,,Outpatient,,,363,363,,,,,,Other,Not Separately Reimbursable,299.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,299.48,82.5,,239.584,percent of total billed charges,Pays at 82.5% of total Billed charges,264.99,73,,211.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,254.1,70,,203.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.66,19.19,,55.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,181.5,50,,145.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.66,299.48,
MULTIVITAMIN (THERAGRAN)TAB:,25101375,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
MACRODANTIN (NITROFURANTOIN) CAP : 50MG,25101385,CDM,250,RC,Q0164,HCPCS,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
COMPAZINE(PROCHLORPERAZINE)TAB :5MG,25101415,CDM,250,RC,C9113,HCPCS,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
PANTOPRAZOLE(PROTONIX)INJ:40MG,25101435,CDM,636,RC,C9113,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
PROTONIX DRIP 80 MG/80 ML NS,25101436,CDM,636,RC,C9113,HCPCS,Outpatient,,,99,99,,,,,,Other,Not Separately Reimbursable,81.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,81.68,82.5,,65.344,percent of total billed charges,Pays at 82.5% of total Billed charges,72.27,73,,57.816,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.3,70,,55.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,19.19,,15.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.5,50,,39.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,81.68,
PROTONIX DRIP 40 MG/40 ML NS,25101437,CDM,636,RC,,,Outpatient,,,99,99,,,,,,Other,Not Separately Reimbursable,81.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,81.68,82.5,,65.344,percent of total billed charges,Pays at 82.5% of total Billed charges,72.27,73,,57.816,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.3,70,,55.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,19.19,,15.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.5,50,,39.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,81.68,
LANOXIN(DIGOXIN)SOLN:0.125MG/2.5ML,25101440,CDM,250,RC,,,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
SUCRALFATE(CARAFATE)TAB:1GM,25101445,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
COGENTIN(BENZTROPINE)TAB:2MG,25101450,CDM,250,RC,,,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
BENZTROPINE(COGENTIN)TAB:1MG,25101455,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
LANOXIN(DIGOXIN)SOLN:0.25MG/5ML,25101465,CDM,250,RC,,,Outpatient,,,8,8,,,,,,Other,Not Separately Reimbursable,6.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6.6,82.5,,5.28,percent of total billed charges,Pays at 82.5% of total Billed charges,5.84,73,,4.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.6,70,,4.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,19.19,,1.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4,50,,3.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,6.6,
MORPHINE IMMEDIATE RELEASE TAB: 15 MG,25101470,CDM,250,RC,J2274,HCPCS,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
MORPHINE PCA: 1MG/ML 30 ML,25101475,CDM,636,RC,,,Outpatient,,,141,141,,,,,,Other,Not Separately Reimbursable,116.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,116.33,82.5,,93.064,percent of total billed charges,Pays at 82.5% of total Billed charges,102.93,73,,82.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.7,70,,78.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,19.19,,21.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.5,50,,56.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,116.33,
GUAIFENESIN(ROBITUSSIN)LIQ:10ML,25101480,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
PHENYTOIN(DILANTIN)CHEWABLE TAB:50MG,25101500,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
GUAIFENESIN DM(ROBITUSSIN)LIQ:10ML,25101540,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SAFETUSSIN(GUAIFEN/DEXTROM)SF:10 ML,25101545,CDM,250,RC,,,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
LEVOTHYROXINE (SYNTHROID)TAB:0.05MG,25101560,CDM,250,RC,,,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
MECLIZINE(ANTIVERT)TAB:12.5MG,25101565,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
PREMARIN (CONJ.ESTROGEN)TAB:0.625MG,25101575,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SULFAMETH/TRIMET(BACTRIM DS)TAB: 800/160,25101585,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
KEFLEX(CEPHALEXIN)CAP:250MG,25101590,CDM,250,RC,,,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
CEPHALEXIN(KEFLEX)CAP:500MG,25101595,CDM,250,RC,J1815,HCPCS,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
INSULIN REGULAR HUMULIN/NOVOLIN,25101600,CDM,250,RC,,,Outpatient,,,1,1,,,,,,Other,Not Separately Reimbursable,0.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,0.83,82.5,,0.664,percent of total billed charges,Pays at 82.5% of total Billed charges,0.73,73,,0.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.7,70,,0.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.19,19.19,,0.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.5,50,,0.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.19,0.83,
BUMETANIDE(BUMEX)INJ:1MG/4ML,25101640,CDM,250,RC,,,Outpatient,,,26,26,,,,,,Other,Not Separately Reimbursable,21.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,21.45,82.5,,17.16,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,73,,15.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.2,70,,14.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,19.19,,3.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13,50,,10.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,21.45,
DOCUSATE SODIUM(COLACE)LIQ:100MG/10ML,25101650,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
NEOSPORIN(TRIPLE ANTIBIOTIC)OINT:15 GM,25101660,CDM,250,RC,,,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,9.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.9,82.5,,7.92,percent of total billed charges,Pays at 82.5% of total Billed charges,8.76,73,,7.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.4,70,,6.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,19.19,,1.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6,50,,4.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,9.9,
MAG-AL PLUS(MAALOX PLUS)LIQ: 30ML,25101705,CDM,250,RC,J0690,HCPCS,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
CEFAZOLIN(ANCEF)VIAL:1GM,25101715,CDM,636,RC,,,Outpatient,,,27,27,,,,,,Other,Not Separately Reimbursable,22.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,22.28,82.5,,17.824,percent of total billed charges,Pays at 82.5% of total Billed charges,19.71,73,,15.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.9,70,,15.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,19.19,,4.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.5,50,,10.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,22.28,
VERAPAMIL SR(ISOPTIN SR)TAB:180 MG,25101720,CDM,250,RC,,,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
ATENOLOL (TENORMIN) TAB: 25 MG,25101725,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FERROUS SULFATE TAB:325MG,25101830,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
THERAGRAN M(MULTIVITAMIN)TAB:,25101845,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
PREDNISONE 20MG TAB,25101900,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FAMOTIDINE(PEPCID)TAB:20MG,25101915,CDM,250,RC,,,Outpatient,,,8,8,,,,,,Other,Not Separately Reimbursable,6.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6.6,82.5,,5.28,percent of total billed charges,Pays at 82.5% of total Billed charges,5.84,73,,4.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.6,70,,4.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,19.19,,1.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4,50,,3.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,6.6,
FAMOTIDINE(PEPCID)INJ:20MG,25101920,CDM,250,RC,,,Outpatient,,,22,22,,,,,,Other,Not Separately Reimbursable,18.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.15,82.5,,14.52,percent of total billed charges,Pays at 82.5% of total Billed charges,16.06,73,,12.848,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.4,70,,12.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,19.19,,3.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11,50,,8.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,18.15,
ACETAMINOPHEN SYRUP:1000MG/31ML,25101940,CDM,250,RC,J1245,HCPCS,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
PERSANTINE(DIPYRIDAMOLE)INJ:10 MG,25101945,CDM,250,RC,J1245,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
PERSANTINE(DIPYRIDAMOLE)INJ:50 MG,25101946,CDM,250,RC,,,Outpatient,,,370,370,,,,,,Other,Not Separately Reimbursable,305.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,305.25,82.5,,244.2,percent of total billed charges,Pays at 82.5% of total Billed charges,270.1,73,,216.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,259,70,,207.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,19.19,,56.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,185,50,,148,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,305.25,
DICYCLOMINE(BENTYL)CAP:10MG,25101950,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
PROVENTIL (ALBUTEROL) SYRUP: 2MG/5ML,25101985,CDM,250,RC,J1742,HCPCS,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
CORVERT(IBUTILIDE)INJ: 1 MG,25101995,CDM,636,RC,,,Outpatient,,,843,843,,,,,,Other,Not Separately Reimbursable,695.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,695.48,82.5,,556.384,percent of total billed charges,Pays at 82.5% of total Billed charges,615.39,73,,492.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,590.1,70,,472.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.77,19.19,,129.416,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,421.5,50,,337.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.77,695.48,
DIVALPROEX(DEPAKOTE)DR TAB:250MG,25102000,CDM,250,RC,,,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,14.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.85,82.5,,11.88,percent of total billed charges,Pays at 82.5% of total Billed charges,13.14,73,,10.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,70,,10.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,19.19,,2.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9,50,,7.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,14.85,
METOLAZONE(ZAROXOLYN)TAB:5MG,25102055,CDM,250,RC,,,Outpatient,,,7,7,,,,,,Other,Not Separately Reimbursable,5.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5.78,82.5,,4.624,percent of total billed charges,Pays at 82.5% of total Billed charges,5.11,73,,4.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.9,70,,3.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,19.19,,1.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,50,,2.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,5.78,
FERROUS SULFATE ELIXIR : 5ML,25102065,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
GEMFIBROZIL(LOPID)TAB:600MG,25102090,CDM,250,RC,,,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,9.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.9,82.5,,7.92,percent of total billed charges,Pays at 82.5% of total Billed charges,8.76,73,,7.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.4,70,,6.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,19.19,,1.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6,50,,4.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,9.9,
CHLORDIAZEPOXIDE(LIBRIUM)CAP:25MG,25102100,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SILVADENE(SILVER SULFADIAZENE)CREAM:400G,25102140,CDM,250,RC,,,Outpatient,,,208,208,,,,,,Other,Not Separately Reimbursable,171.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,171.6,82.5,,137.28,percent of total billed charges,Pays at 82.5% of total Billed charges,151.84,73,,121.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,145.6,70,,116.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.92,19.19,,31.936,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104,50,,83.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.92,171.6,
HYDROCODONE 5MG/APAP 325MG(LORTAB)TAB,25102180,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ALLOPURINOL(ZYLOPRIM)TAB:100MG,25102200,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
POTASSIUM CL(K-DUR)TAB:20 MEQ,25102220,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ACETAMINOPHEN(TYLENOL)TAB:325 MG,25102245,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
AMOXICILLIN CAP:250MG,25102250,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
AMOXICILLIN CAP:500MG,25102255,CDM,250,RC,,,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
DOXYCYCLINE(VIBRAMYCIN)CAP:100MG,25102300,CDM,250,RC,,,Outpatient,,,17,17,,,,,,Other,Not Separately Reimbursable,14.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.03,82.5,,11.224,percent of total billed charges,Pays at 82.5% of total Billed charges,12.41,73,,9.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,70,,9.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.26,19.19,,2.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.5,50,,6.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.26,14.03,
PROPRANOLOL(INDERAL)TAB:10MG,25102305,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FOLIC ACID TAB: 1 MG,25102315,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
LOPERAMIDE(IMODIUM)TAB:2MG,25102325,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
PHENERGAN (PROMETHAZINE) SYRUP : 10ML,25102335,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
ACETAMINOPHEN LIQ(TYLENOL):325MG/10.15ML,25102355,CDM,250,RC,,,Outpatient,,,8,8,,,,,,Other,Not Separately Reimbursable,6.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6.6,82.5,,5.28,percent of total billed charges,Pays at 82.5% of total Billed charges,5.84,73,,4.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.6,70,,4.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,19.19,,1.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4,50,,3.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,6.6,
ACETAMINOPHEN LIQ(TYLENOL):160MG/5ML,25102356,CDM,250,RC,,,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,9.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.08,82.5,,7.264,percent of total billed charges,Pays at 82.5% of total Billed charges,8.03,73,,6.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.7,70,,6.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,19.19,,1.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.5,50,,4.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,9.08,
METOCLOPRAMIDE(REGLAN)TAB:10MG,25102420,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
MOTRIN(IBUPROFEN)LIQ:100MG/5 ML,25102425,CDM,250,RC,,,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
CLOTRIMAZOLE/BETAMETHASONE)CR:15GM,25102430,CDM,250,RC,,,Outpatient,,,216,216,,,,,,Other,Not Separately Reimbursable,178.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,178.2,82.5,,142.56,percent of total billed charges,Pays at 82.5% of total Billed charges,157.68,73,,126.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.2,70,,120.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.45,19.19,,33.16,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108,50,,86.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.45,178.2,
CLONIDINE TDS-1 PATCH:0.1MG,25102435,CDM,250,RC,,,Outpatient,,,232,232,,,,,,Other,Not Separately Reimbursable,191.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,191.4,82.5,,153.12,percent of total billed charges,Pays at 82.5% of total Billed charges,169.36,73,,135.488,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,162.4,70,,129.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.52,19.19,,35.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116,50,,92.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.52,191.4,
CARBAMIDE PEROXIDE 6.5%:15ML,25102440,CDM,250,RC,,,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
SPIRONOLACTONE(ALDACTONE)TAB:25MG,25102465,CDM,250,RC,J3420,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CYANOCOBALAMIN(VIT B-12)INJ:1000MCG,25102540,CDM,250,RC,,,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,75.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,75.9,82.5,,60.72,percent of total billed charges,Pays at 82.5% of total Billed charges,67.16,73,,53.728,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.4,70,,51.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,19.19,,14.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46,50,,36.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,75.9,
VIT B-12 TAB(CYANOCOBALAMIN) 1000MCG,25102541,CDM,250,RC,J1630,HCPCS,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
HALOPERIDOL(HALDOL)INJ:5MG/ML,25102585,CDM,250,RC,,,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
MUPIROCIN 2%(BACTROBAN)OINT:22GM,25102600,CDM,250,RC,,,Outpatient,,,175,175,,,,,,Other,Not Separately Reimbursable,144.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,144.38,82.5,,115.504,percent of total billed charges,Pays at 82.5% of total Billed charges,127.75,73,,102.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.5,70,,98,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.58,19.19,,26.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,50,,70,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.58,144.38,
BACTROBAN(MUPIROCIN)NASAL 2% OINT:1 GM,25102605,CDM,250,RC,,,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,20.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,20.63,82.5,,16.504,percent of total billed charges,Pays at 82.5% of total Billed charges,18.25,73,,14.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,70,,14,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,19.19,,3.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,50,,10,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,20.63,
BACTROBAN(MUPIROCIN)2% OINT:1 GM,25102606,CDM,250,RC,,,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
LEVOTHYROXINE (SYNTHROID)TAB:0.075MG,25102610,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DONNATAL ELIX : 10ML,25102630,CDM,250,RC,,,Outpatient,,,8,8,,,,,,Other,Not Separately Reimbursable,6.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6.6,82.5,,5.28,percent of total billed charges,Pays at 82.5% of total Billed charges,5.84,73,,4.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.6,70,,4.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,19.19,,1.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4,50,,3.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,6.6,
NTG OINTMENT : 2% 1 INCH,25102635,CDM,250,RC,,,Outpatient,,,26,26,,,,,,Other,Not Separately Reimbursable,21.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,21.45,82.5,,17.16,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,73,,15.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.2,70,,14.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,19.19,,3.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13,50,,10.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,21.45,
HYTRIN(TERAZOSIN)CAP:2MG,25102680,CDM,250,RC,,,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
ACETAMINOPHEN(TYLENOL)ES TAB:500 MG,25102720,CDM,250,RC,,,Outpatient,,,2,2,,,,,,Other,Not Separately Reimbursable,1.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1.65,82.5,,1.32,percent of total billed charges,Pays at 82.5% of total Billed charges,1.46,73,,1.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.4,70,,1.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.38,19.19,,0.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1,50,,0.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.38,1.65,
KAYEXALATE(SOD.POLYSTYREN)ENEMA 30GM:,25102730,CDM,250,RC,,,Outpatient,,,61,61,,,,,,Other,Not Separately Reimbursable,50.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,50.33,82.5,,40.264,percent of total billed charges,Pays at 82.5% of total Billed charges,44.53,73,,35.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.7,70,,34.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,19.19,,9.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.5,50,,24.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,50.33,
KAYEXALATE(SOD.POLYSTYRENE)LIQ:15GM/60ML,25102740,CDM,250,RC,,,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,69.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,69.3,82.5,,55.44,percent of total billed charges,Pays at 82.5% of total Billed charges,61.32,73,,49.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.8,70,,47.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,19.19,,12.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,50,,33.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,69.3,
CARISOPRODOL(SOMA)TAB:350MG,25102750,CDM,250,RC,J0696,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CEFTRIAXONE(ROCEPHIN)INJ:250MG,25102805,CDM,636,RC,J0696,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
CEFTRIAXONE (ROCEPHIN)INJ:1 GM,25102815,CDM,636,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
THEO-DUR(THEOPHYLLINE)TAB:100 MG,25102830,CDM,250,RC,,,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
FLORINEF(FLUDROCORTISONE)TAB:0.1MG,25102860,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
CLONAZEPAM TAB:1MG,25102940,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
LOTRIMIN(CLOTRIMAZOLE)CR 15GM:1%,25102975,CDM,250,RC,,,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
NYSTATIN ORAL SUSP:5ML,25102990,CDM,250,RC,,,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,9.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.9,82.5,,7.92,percent of total billed charges,Pays at 82.5% of total Billed charges,8.76,73,,7.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.4,70,,6.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,19.19,,1.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6,50,,4.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,9.9,
TRAZODONE(DESYREL)TAB:50MG,25103025,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
NYSTATIN/TRIAMCIN CR : 15GM,25103130,CDM,250,RC,,,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,9.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.08,82.5,,7.264,percent of total billed charges,Pays at 82.5% of total Billed charges,8.03,73,,6.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.7,70,,6.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,19.19,,1.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.5,50,,4.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,9.08,
PREMARIN (CONJ.ESTROGEN)TAB:0.3MG,25103140,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
HydraLAZINE(APRESOLINE)TAB:25MG,25103175,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
TOBREX(TOBRAMYCIN)OS 5ML:,25103210,CDM,250,RC,,,Outpatient,,,41,41,,,,,,Other,Not Separately Reimbursable,33.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33.83,82.5,,27.064,percent of total billed charges,Pays at 82.5% of total Billed charges,29.93,73,,23.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.7,70,,22.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,19.19,,6.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.5,50,,16.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,33.83,
SIMETHICONE(MYLANTA GAS)TAB:80 MG,25103365,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
diphenhydrAMINE(BENADRYL)ELIX:12.5MG/5ML,25103420,CDM,250,RC,J0461,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ATROPINE INJ:0.4MG,25103455,CDM,250,RC,,,Outpatient,,,44,44,,,,,,Other,Not Separately Reimbursable,36.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,36.3,82.5,,29.04,percent of total billed charges,Pays at 82.5% of total Billed charges,32.12,73,,25.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.8,70,,24.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,19.19,,6.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22,50,,17.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,36.3,
BETADINE(POVIDONE-IODINE)DOUCHE:,25103485,CDM,250,RC,,,Outpatient,,,37,37,,,,,,Other,Not Separately Reimbursable,30.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,30.53,82.5,,24.424,percent of total billed charges,Pays at 82.5% of total Billed charges,27.01,73,,21.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.9,70,,20.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,19.19,,5.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.5,50,,14.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,30.53,
SODIUM CHLORIDE TAB:1GM,25103505,CDM,250,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
GOLYTELY PREP 1 GAL,25103540,CDM,250,RC,86580,HCPCS,Outpatient,,,67,67,,,,,,Other,Not Separately Reimbursable,55.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,55.28,82.5,,44.224,percent of total billed charges,Pays at 82.5% of total Billed charges,48.91,73,,39.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,70,,37.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,19.19,,10.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.5,50,,26.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,55.28,
PPD 0.1ML INJ,25103560,CDM,302,RC,J3411,HCPCS,Outpatient,,,93,93,,,,,,Other,Not Separately Reimbursable,76.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,76.73,82.5,,61.384,percent of total billed charges,Pays at 82.5% of total Billed charges,67.89,73,,54.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.1,70,,52.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.85,19.19,,14.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.5,50,,37.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.85,76.73,
THIAMINE INJ:100MG/ML 2ML (200MG),25103600,CDM,250,RC,,,Outpatient,,,125,125,,,,,,Other,Not Separately Reimbursable,103.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,103.13,82.5,,82.504,percent of total billed charges,Pays at 82.5% of total Billed charges,91.25,73,,73,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,70,,70,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,19.19,,19.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.5,50,,50,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,103.13,
SODIUM BICARBONATE 8.4%:50 ML SYR,25103625,CDM,250,RC,,,Outpatient,,,105,105,,,,,,Other,Not Separately Reimbursable,86.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,86.63,82.5,,69.304,percent of total billed charges,Pays at 82.5% of total Billed charges,76.65,73,,61.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.5,70,,58.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,19.19,,16.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,50,,42,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,86.63,
SODIUM BICARBONATE 8.4%:50 ML VIAL,25103626,CDM,250,RC,,,Outpatient,,,102,102,,,,,,Other,Not Separately Reimbursable,84.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,84.15,82.5,,67.32,percent of total billed charges,Pays at 82.5% of total Billed charges,74.46,73,,59.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.4,70,,57.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,19.19,,15.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51,50,,40.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,84.15,
SODIUM BICARBONATE 3 AMPS IN 1000 ML D5W,25103627,CDM,250,RC,,,Outpatient,,,72,72,,,,,,Other,Not Separately Reimbursable,59.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,59.4,82.5,,47.52,percent of total billed charges,Pays at 82.5% of total Billed charges,52.56,73,,42.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.4,70,,40.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,19.19,,11.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36,50,,28.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,59.4,
TRIAMICIN(KENALOG):5MG,25103645,CDM,250,RC,J3301,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,27.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.23,82.5,,21.784,percent of total billed charges,Pays at 82.5% of total Billed charges,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,27.23,
TRIAMCINOLONE(KENALOG)INJ:40MG,25103647,CDM,250,RC,J2270,HCPCS,Outpatient,,,83,83,,,,,,Other,Not Separately Reimbursable,68.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,68.48,82.5,,54.784,percent of total billed charges,Pays at 82.5% of total Billed charges,60.59,73,,48.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.1,70,,46.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.93,19.19,,12.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.5,50,,33.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.93,68.48,
MORPHINE SULFATE INJ:10MG,25103690,CDM,636,RC,J2270,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,26.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,26.4,82.5,,21.12,percent of total billed charges,Pays at 82.5% of total Billed charges,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,26.4,
MORPHINE DRIP 1 MG/ML 50 MG IN 50 ML NS,25103691,CDM,636,RC,,,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
CITRATE OF MAGNESIA LIQ : 300ML,25103695,CDM,250,RC,,,Outpatient,,,22,22,,,,,,Other,Not Separately Reimbursable,18.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.15,82.5,,14.52,percent of total billed charges,Pays at 82.5% of total Billed charges,16.06,73,,12.848,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.4,70,,12.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,19.19,,3.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11,50,,8.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,18.15,
MECLOFENAMATE CAP : 50MG,25103750,CDM,250,RC,,,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
CEFDINIR(OMNICEF)SUSP 125MG:5ML,25103755,CDM,250,RC,,,Outpatient,,,41,41,,,,,,Other,Not Separately Reimbursable,33.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33.83,82.5,,27.064,percent of total billed charges,Pays at 82.5% of total Billed charges,29.93,73,,23.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.7,70,,22.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,19.19,,6.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.5,50,,16.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,33.83,
CEFDINIR (OMNICEF) CAP: 300MG,25103765,CDM,250,RC,,,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,25.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,25.58,82.5,,20.464,percent of total billed charges,Pays at 82.5% of total Billed charges,22.63,73,,18.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.7,70,,17.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,19.19,,4.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.5,50,,12.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,25.58,
SALINE 3% 500 ML,25103770,CDM,258,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
QUEtiapine(SEROQUEL)TAB:25MG,25103775,CDM,250,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
QUEtiapine(SEROQUEL)TAB:100MG,25103780,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SALIVA SUBSTITUTE : 180ML,25103835,CDM,250,RC,,,Outpatient,,,16,16,,,,,,Other,Not Separately Reimbursable,13.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13.2,82.5,,10.56,percent of total billed charges,Pays at 82.5% of total Billed charges,11.68,73,,9.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.2,70,,8.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,19.19,,2.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8,50,,6.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,13.2,
PHENAZOPYRIDINE (PYRIDIUM) TAB : 100MG,25103840,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SEPTRA(SULFAMETH/TRIMETH)SUSP:20 ML,25103870,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SEPTRA(SULFAMETH/TRIMETH)SUSP:5 ML,25103871,CDM,250,RC,J1885,HCPCS,Outpatient,,,23,23,,,,,,Other,Not Separately Reimbursable,18.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,82.5,,15.184,percent of total billed charges,Pays at 82.5% of total Billed charges,16.79,73,,13.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.1,70,,12.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,19.19,,3.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.5,50,,9.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,18.98,
TORADOL(KETORALAC)INJ:15MG,25103930,CDM,250,RC,J1885,HCPCS,Outpatient,,,43,43,,,,,,Other,Not Separately Reimbursable,35.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,35.48,82.5,,28.384,percent of total billed charges,Pays at 82.5% of total Billed charges,31.39,73,,25.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.1,70,,24.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,19.19,,6.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.5,50,,17.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,35.48,
KETOROLAC(TORADOL)INJ:30MG,25103935,CDM,250,RC,J1885,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
KETOROLAC(TORADOL)INJ:60MG,25103940,CDM,250,RC,,,Outpatient,,,115,115,,,,,,Other,Not Separately Reimbursable,94.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,94.88,82.5,,75.904,percent of total billed charges,Pays at 82.5% of total Billed charges,83.95,73,,67.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.5,70,,64.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.07,19.19,,17.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.5,50,,46,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.07,94.88,
NEOMYCIN-POLYMYXIN-HC OTIC SOLN: 10ML,25104110,CDM,250,RC,,,Outpatient,,,300,300,,,,,,Other,Not Separately Reimbursable,247.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,247.5,82.5,,198,percent of total billed charges,Pays at 82.5% of total Billed charges,219,73,,175.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,210,70,,168,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.57,19.19,,46.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,150,50,,120,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.57,247.5,
SYMMETREL (AMANTADINE) CAP:100MG,25104220,CDM,250,RC,90714,HCPCS,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
DIPHTHERIA TETANUS ADULT (Td),25104345,CDM,250,RC,J2430,HCPCS,Outpatient,,,567,567,,,,,,Other,Not Separately Reimbursable,467.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,467.78,82.5,,374.224,percent of total billed charges,Pays at 82.5% of total Billed charges,413.91,73,,331.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,396.9,70,,317.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108.81,19.19,,87.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,283.5,50,,226.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108.81,467.78,
AREDIA (PAMIDRONATE) 30MG IN 500ML 1/2NS,25104360,CDM,636,RC,J2430,HCPCS,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
AREDIA(PAMIDRONATE) 90 MG IN 1000ML1/2NS,25104362,CDM,636,RC,,,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
CARDIZEM CD(DILTIAZEM)CAP:300MG,25104365,CDM,250,RC,,,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,7.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,7.43,82.5,,5.944,percent of total billed charges,Pays at 82.5% of total Billed charges,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,7.43,
COLCHICINE(COLCRYS)TAB:0.6MG,25104511,CDM,250,RC,,,Outpatient,,,68,68,,,,,,Other,Not Separately Reimbursable,56.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.1,82.5,,44.88,percent of total billed charges,Pays at 82.5% of total Billed charges,49.64,73,,39.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.6,70,,38.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,19.19,,10.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34,50,,27.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,56.1,
ACTIDOSE/SORBITOL: 50GM,25104540,CDM,250,RC,,,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,78.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,78.38,82.5,,62.704,percent of total billed charges,Pays at 82.5% of total Billed charges,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,78.38,
DICLOXACILLIN 500MG CAP,25104580,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
CHOLESTYRAMINE(QUESTRAN)PWD:4GM,25104600,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ERYTHROMYCIN OPTH OINT:UD,25104660,CDM,250,RC,,,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
LACTULOSE(20GM/30ML)SOLN:30ML,25104690,CDM,250,RC,J8540,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DEXAMETHASONE(DECADRON)TAB:4MG,25104710,CDM,250,RC,,,Outpatient,,,7,7,,,,,,Other,Not Separately Reimbursable,5.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5.78,82.5,,4.624,percent of total billed charges,Pays at 82.5% of total Billed charges,5.11,73,,4.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.9,70,,3.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,19.19,,1.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,50,,2.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,5.78,
DEXAMETHASONE TAB:2MG,25104711,CDM,250,RC,,,Outpatient,,,7,7,,,,,,Other,Not Separately Reimbursable,5.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5.78,82.5,,4.624,percent of total billed charges,Pays at 82.5% of total Billed charges,5.11,73,,4.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.9,70,,3.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,19.19,,1.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,50,,2.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,5.78,
DEPAKOTE (DIVALPROEX SOD) TAB : 500MG,25104715,CDM,250,RC,,,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
LISINOPRIL(ZESTRIL)TAB:5MG,25104720,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FLUORESCEIN OPHTHALMIC STRIP,25104740,CDM,250,RC,,,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,7.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,7.43,82.5,,5.944,percent of total billed charges,Pays at 82.5% of total Billed charges,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,7.43,
TETRACAINE 0.5% OPHTH SOLN:2ML,25104745,CDM,250,RC,,,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,69.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,69.3,82.5,,55.44,percent of total billed charges,Pays at 82.5% of total Billed charges,61.32,73,,49.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.8,70,,47.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,19.19,,12.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,50,,33.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,69.3,
DYAZIDE/MAXZIDE(TRIA/HCT):37.5/25,25104765,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ACETAMINOPHEN(TYLENOL)SUPP:120MG,25104770,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
GI COCKTAIL : 30ML,25104800,CDM,250,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CARVEDILOL(COREG)TAB:3.125MG,25104875,CDM,250,RC,,,Outpatient,,,21,21,,,,,,Other,Not Separately Reimbursable,17.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,17.33,82.5,,13.864,percent of total billed charges,Pays at 82.5% of total Billed charges,15.33,73,,12.264,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.7,70,,11.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,19.19,,3.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,50,,8.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,17.33,
AMMONIA INHALANT,25104885,CDM,250,RC,,,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,7.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,7.43,82.5,,5.944,percent of total billed charges,Pays at 82.5% of total Billed charges,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,7.43,
BENZONATATE(TESSALON)CAP:100MG,25104980,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
THIAMINE(VITAMIN B-1)TAB:50MG,25105100,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
NEOSPORIN OPTH SOLN:10ML,25105140,CDM,250,RC,,,Outpatient,,,496,496,,,,,,Other,Not Separately Reimbursable,409.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,409.2,82.5,,327.36,percent of total billed charges,Pays at 82.5% of total Billed charges,362.08,73,,289.664,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,347.2,70,,277.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.18,19.19,,76.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,248,50,,198.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.18,409.2,
ASPIRIN SUPP:300MG,25105270,CDM,250,RC,G8598,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,9.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.9,82.5,,7.92,percent of total billed charges,Pays at 82.5% of total Billed charges,8.76,73,,7.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.4,70,,6.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,19.19,,1.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6,50,,4.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,9.9,
ASPIRIN EC(ECOTRIN)TAB:81MG,25105275,CDM,250,RC,J0295,HCPCS,Outpatient,,,2,2,,,,,,Other,Not Separately Reimbursable,1.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1.65,82.5,,1.32,percent of total billed charges,Pays at 82.5% of total Billed charges,1.46,73,,1.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.4,70,,1.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.38,19.19,,0.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1,50,,0.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.38,1.65,
UNASYN(AMPICILLIN/SULBACTAM):1.5 GM,25105290,CDM,250,RC,,,Outpatient,,,34,34,,,,,,Other,Not Separately Reimbursable,28.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.05,82.5,,22.44,percent of total billed charges,Pays at 82.5% of total Billed charges,24.82,73,,19.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,70,,19.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,19.19,,5.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17,50,,13.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,28.05,
GENTAMICIN CR/OINT 15 GM:0.1%,25105300,CDM,250,RC,,,Outpatient,,,41,41,,,,,,Other,Not Separately Reimbursable,33.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33.83,82.5,,27.064,percent of total billed charges,Pays at 82.5% of total Billed charges,29.93,73,,23.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.7,70,,22.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,19.19,,6.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.5,50,,16.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,33.83,
OXYBUTYNIN(DITROPAN)TAB:5MG,25105370,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ANTIPYRINE/BENZO(AURALGAN)OTIC:15ML,25105400,CDM,250,RC,,,Outpatient,,,104,104,,,,,,Other,Not Separately Reimbursable,85.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,85.8,82.5,,68.64,percent of total billed charges,Pays at 82.5% of total Billed charges,75.92,73,,60.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.8,70,,58.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.96,19.19,,15.968,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52,50,,41.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.96,85.8,
CORTISPORIN OPTH SUSP:7.5ML,25105430,CDM,250,RC,,,Outpatient,,,61,61,,,,,,Other,Not Separately Reimbursable,50.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,50.33,82.5,,40.264,percent of total billed charges,Pays at 82.5% of total Billed charges,44.53,73,,35.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.7,70,,34.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,19.19,,9.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.5,50,,24.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,50.33,
GENTAMICIN 0.3% OPTH SOL:5ML,25105440,CDM,250,RC,,,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,71.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,71.78,82.5,,57.424,percent of total billed charges,Pays at 82.5% of total Billed charges,63.51,73,,50.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.9,70,,48.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,19.19,,13.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.5,50,,34.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,71.78,
GARAMYCIN(GENTAMYCIN)OPTH OINT:,25105520,CDM,250,RC,,,Outpatient,,,158,158,,,,,,Other,Not Separately Reimbursable,130.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,130.35,82.5,,104.28,percent of total billed charges,Pays at 82.5% of total Billed charges,115.34,73,,92.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110.6,70,,88.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.32,19.19,,24.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79,50,,63.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.32,130.35,
TYLENOL/CODEINE SYRUP : 5ML,25105530,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
TOLTERODINE LA(DETROL)CAP:4MG,25105736,CDM,250,RC,,,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
guaiFENesin LA(MUCINEX LA)TAB:600MG,25105766,CDM,250,RC,,,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
GUAIFENSIN DM(ROBITUSSIN)LIQ:5ML,25105800,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
DULOXETINE DR (CYMBALTA)CAP:30MG,25106010,CDM,250,RC,,,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
IPECAC SYRUP : 30ML,25106020,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ACTIDOSE AQUA:25GM,25106030,CDM,250,RC,,,Outpatient,,,179,179,,,,,,Other,Not Separately Reimbursable,147.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,147.68,82.5,,118.144,percent of total billed charges,Pays at 82.5% of total Billed charges,130.67,73,,104.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125.3,70,,100.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.35,19.19,,27.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.5,50,,71.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.35,147.68,
LABETALOL(NORMODYNE)INJ:100MG,25106035,CDM,250,RC,,,Outpatient,,,128,128,,,,,,Other,Not Separately Reimbursable,105.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,105.6,82.5,,84.48,percent of total billed charges,Pays at 82.5% of total Billed charges,93.44,73,,74.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.6,70,,71.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,19.19,,19.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64,50,,51.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,105.6,
NORMODYNE(LABETOLOL)INJ:200MG,25106036,CDM,250,RC,,,Outpatient,,,250,250,,,,,,Other,Not Separately Reimbursable,206.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,206.25,82.5,,165,percent of total billed charges,Pays at 82.5% of total Billed charges,182.5,73,,146,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,70,,140,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,19.19,,38.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125,50,,100,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,206.25,
NORMODYNE(LABETOLOL) DRIP,25106037,CDM,250,RC,,,Outpatient,,,128,128,,,,,,Other,Not Separately Reimbursable,105.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,105.6,82.5,,84.48,percent of total billed charges,Pays at 82.5% of total Billed charges,93.44,73,,74.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.6,70,,71.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,19.19,,19.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64,50,,51.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,105.6,
ATROPINE SULF 1% OPTH 5ML,25106040,CDM,250,RC,90371,HCPCS,Outpatient,,,216,216,,,,,,Other,Not Separately Reimbursable,178.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,178.2,82.5,,142.56,percent of total billed charges,Pays at 82.5% of total Billed charges,157.68,73,,126.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.2,70,,120.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.45,19.19,,33.16,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108,50,,86.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.45,178.2,
HEPATITIS B IMM GLOB 5ML,25106045,CDM,636,RC,,,Outpatient,,,4023,4023,,,,,,Other,Not Separately Reimbursable,3318.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3318.98,82.5,,2655.184,percent of total billed charges,Pays at 82.5% of total Billed charges,2936.79,73,,2349.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2816.1,70,,2252.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.01,19.19,,617.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2011.5,50,,1609.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,772.01,3318.98,
NORMODYNE(LABETALOL)INJ:20 MG,25106055,CDM,250,RC,,,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,14.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.85,82.5,,11.88,percent of total billed charges,Pays at 82.5% of total Billed charges,13.14,73,,10.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,70,,10.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,19.19,,2.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9,50,,7.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,14.85,
ACTIDOSE AQUA:50GM,25106260,CDM,250,RC,,,Outpatient,,,265,265,,,,,,Other,Not Separately Reimbursable,218.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,218.63,82.5,,174.904,percent of total billed charges,Pays at 82.5% of total Billed charges,193.45,73,,154.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,185.5,70,,148.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.85,19.19,,40.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.5,50,,106,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.85,218.63,
DIAMOX (ACETAZOLAMIDE)TAB:250MG,25106280,CDM,250,RC,J1642,HCPCS,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
HEPARIN FLUSH: 10U/ML 10ML,25106295,CDM,250,RC,,,Outpatient,,,37,37,,,,,,Other,Not Separately Reimbursable,30.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,30.53,82.5,,24.424,percent of total billed charges,Pays at 82.5% of total Billed charges,27.01,73,,21.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.9,70,,20.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,19.19,,5.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.5,50,,14.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,30.53,
CETACAINE(TETRACAINE)SPRY:,25106330,CDM,250,RC,,,Outpatient,,,246,246,,,,,,Other,Not Separately Reimbursable,202.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,202.95,82.5,,162.36,percent of total billed charges,Pays at 82.5% of total Billed charges,179.58,73,,143.664,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,172.2,70,,137.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.21,19.19,,37.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,123,50,,98.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.21,202.95,
EMLA (LIDOCAINE/PRILOCAINE) CR,25106365,CDM,250,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
KWELL (LINDANE) LOTION : 60ML,25106370,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
METOLAZONE(ZAROXOLYN)TAB:2.5MG,25106390,CDM,250,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CITALOPRAM(CELEXA)TAB:20MG,25106395,CDM,250,RC,,,Outpatient,,,27,27,,,,,,Other,Not Separately Reimbursable,22.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,22.28,82.5,,17.824,percent of total billed charges,Pays at 82.5% of total Billed charges,19.71,73,,15.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.9,70,,15.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,19.19,,4.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.5,50,,10.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,22.28,
ESCITALOPRAM(LEXAPRO)TAB:10MG,25106405,CDM,250,RC,,,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
TUSSIONEX SUSP:5 ML,25106592,CDM,250,RC,,,Outpatient,,,17,17,,,,,,Other,Not Separately Reimbursable,14.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.03,82.5,,11.224,percent of total billed charges,Pays at 82.5% of total Billed charges,12.41,73,,9.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,70,,9.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.26,19.19,,2.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.5,50,,6.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.26,14.03,
LEVOTHYROXINE (SYNTHROID)TAB:0.025MG,25106660,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CARBIDOPA/LEVODOPA 25/100 :1 TAB,25106670,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
GLYCERIN SUPP ADULT,25106780,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
GLYCERIN SUPP PED,25106781,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
RIFAMPIN 150MG CAP,25106835,CDM,250,RC,,,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,7.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,7.43,82.5,,5.944,percent of total billed charges,Pays at 82.5% of total Billed charges,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,7.43,
ZINC SULFATE CAP:220MG,25106840,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
GI COCKTAIL : 15ML,25106880,CDM,250,RC,J0702,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
Injection to treat reaction to a drug,25107122,CDM,636,RC,,,Outpatient,,,360,360,,,,,,Other,Not Separately Reimbursable,297,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,297,82.5,,237.6,percent of total billed charges,Pays at 82.5% of total Billed charges,262.8,73,,210.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252,70,,201.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,19.19,,55.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180,50,,144,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,297,
CALCIUM CARB(TUMS)TAB:500MG,25107260,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DILTIAZEM ER(CARDIZEM)CAP:180MG,25107370,CDM,250,RC,,,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,15.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,15.68,82.5,,12.544,percent of total billed charges,Pays at 82.5% of total Billed charges,13.87,73,,11.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.3,70,,10.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,19.19,,2.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.5,50,,7.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,15.68,
TRIAMCINOLONE(KENALOG)CR 0.1%:15GM,25107530,CDM,250,RC,,,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
FOLIC ACID INJ: 5 MG/ML,25107660,CDM,250,RC,J0133,HCPCS,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,47.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.03,82.5,,37.624,percent of total billed charges,Pays at 82.5% of total Billed charges,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,47.03,
ACYCLOVIR 50MG/ML INJ:20ML,25107670,CDM,250,RC,J1815,HCPCS,Outpatient,,,336,336,,,,,,Other,Not Separately Reimbursable,277.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,277.2,82.5,,221.76,percent of total billed charges,Pays at 82.5% of total Billed charges,245.28,73,,196.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,235.2,70,,188.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.48,19.19,,51.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,168,50,,134.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.48,277.2,
GLARGINE(LANTUS)INSULIN,25107685,CDM,250,RC,J1335,HCPCS,Outpatient,,,8,8,,,,,,Other,Not Separately Reimbursable,6.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6.6,82.5,,5.28,percent of total billed charges,Pays at 82.5% of total Billed charges,5.84,73,,4.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.6,70,,4.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,19.19,,1.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4,50,,3.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,6.6,
INVANZ(ERTAPENEM)INJ:1 G,25107695,CDM,250,RC,,,Outpatient,,,172,172,,,,,,Other,Not Separately Reimbursable,141.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,141.9,82.5,,113.52,percent of total billed charges,Pays at 82.5% of total Billed charges,125.56,73,,100.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,120.4,70,,96.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.01,19.19,,26.408,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86,50,,68.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.01,141.9,
NICOTINE(NICODERM)PATCH 21MG,25107700,CDM,250,RC,S0020,HCPCS,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,14.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.85,82.5,,11.88,percent of total billed charges,Pays at 82.5% of total Billed charges,13.14,73,,10.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,70,,10.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,19.19,,2.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9,50,,7.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,14.85,
BUPIVICAINE-MPF/EPINEPH 0.25%:10 ML,25107730,CDM,250,RC,,,Outpatient,,,36,36,,,,,,Other,Not Separately Reimbursable,29.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,29.7,82.5,,23.76,percent of total billed charges,Pays at 82.5% of total Billed charges,26.28,73,,21.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.2,70,,20.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,19.19,,5.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18,50,,14.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,29.7,
LIDOCAINE 2%(VISCOUS)SOLN:20ML,25107951,CDM,250,RC,,,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,9.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.08,82.5,,7.264,percent of total billed charges,Pays at 82.5% of total Billed charges,8.03,73,,6.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.7,70,,6.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,19.19,,1.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.5,50,,4.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,9.08,
METHOCARBAMOL(ROBAXIN)TAB:500MG,25107970,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SERTRALINE(ZOLOFT)TAB:50MG,25108150,CDM,250,RC,,,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,23.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.93,82.5,,19.144,percent of total billed charges,Pays at 82.5% of total Billed charges,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,23.93,
SERTRALINE(ZOLOFT)TAB:100MG,25108155,CDM,250,RC,,,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,23.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.1,82.5,,18.48,percent of total billed charges,Pays at 82.5% of total Billed charges,20.44,73,,16.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.6,70,,15.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,19.19,,4.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,50,,11.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,23.1,
NICODERM (NICOTINE) PATCH : 7MG,25108270,CDM,250,RC,,,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
DOXAZOSIN(CARDURA)TAB:2MG,25108290,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
OXYMETAZOLINE SPRAY : 0.05%,25108620,CDM,250,RC,,,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,9.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.08,82.5,,7.264,percent of total billed charges,Pays at 82.5% of total Billed charges,8.03,73,,6.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.7,70,,6.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,19.19,,1.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.5,50,,4.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,9.08,
RAMIPRIL(ALTACE)CAP:5MG,25108710,CDM,250,RC,,,Outpatient,,,21,21,,,,,,Other,Not Separately Reimbursable,17.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,17.33,82.5,,13.864,percent of total billed charges,Pays at 82.5% of total Billed charges,15.33,73,,12.264,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.7,70,,11.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,19.19,,3.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,50,,8.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,17.33,
ALTACE (RAMIPRIL) CAP: 2.5MG,25109000,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
ZITHROMAX(AZITHROMYCIN)SUSP200MG/5ML:5ML,25109055,CDM,250,RC,,,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
AZITHROMYCIN(ZITHROMAX)SUSP200MG/5ML:1ML,25109060,CDM,250,RC,,,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,9.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.9,82.5,,7.92,percent of total billed charges,Pays at 82.5% of total Billed charges,8.76,73,,7.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.4,70,,6.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,19.19,,1.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6,50,,4.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,9.9,
SIMVASTATIN(ZOCOR)TAB:10MG,25109100,CDM,250,RC,,,Outpatient,,,36,36,,,,,,Other,Not Separately Reimbursable,29.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,29.7,82.5,,23.76,percent of total billed charges,Pays at 82.5% of total Billed charges,26.28,73,,21.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.2,70,,20.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,19.19,,5.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18,50,,14.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,29.7,
SIMVASTATIN(ZOCOR)TAB:5MG,25109105,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
AZITHROMYCIN(ZITHROMAX)TAB:250MG,25109110,CDM,250,RC,,,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
SIMVASTATIN(ZOCOR)TAB:20MG,25109115,CDM,250,RC,J1030,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
DepoMEDROL(methylPREDNISOLONE)INJ:40MG,25109180,CDM,250,RC,,,Outpatient,,,86,86,,,,,,Other,Not Separately Reimbursable,70.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.95,82.5,,56.76,percent of total billed charges,Pays at 82.5% of total Billed charges,62.78,73,,50.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.2,70,,48.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,19.19,,13.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43,50,,34.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,70.95,
ACYCLOVIR TAB : 800MG,25109260,CDM,250,RC,,,Outpatient,,,16,16,,,,,,Other,Not Separately Reimbursable,13.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13.2,82.5,,10.56,percent of total billed charges,Pays at 82.5% of total Billed charges,11.68,73,,9.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.2,70,,8.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,19.19,,2.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8,50,,6.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,13.2,
ACYCLOVIR TAB: 400 MG,25109265,CDM,250,RC,S0138,HCPCS,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,7.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,7.43,82.5,,5.944,percent of total billed charges,Pays at 82.5% of total Billed charges,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,7.43,
FINASTERIDE(PROSCAR)TAB:5MG,25109290,CDM,250,RC,,,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,26.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,26.4,82.5,,21.12,percent of total billed charges,Pays at 82.5% of total Billed charges,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,26.4,
VITAMIN C(ASCORBIC)TAB:500MG,25109340,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
BIAXIN (CLARITHROMYCIN)TAB:500MG,25109610,CDM,250,RC,,,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,23.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.93,82.5,,19.144,percent of total billed charges,Pays at 82.5% of total Billed charges,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,23.93,
PHOSPHO-SODA 30ML = 1 OUNCE,25109640,CDM,250,RC,,,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
HYOSCYAMINE(LEVSIN)TAB:0.125MG,25109760,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SIMETHICONE DROPS:40 MG/0.6 ML,25109805,CDM,250,RC,,,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,31.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,31.35,82.5,,25.08,percent of total billed charges,Pays at 82.5% of total Billed charges,27.74,73,,22.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.6,70,,21.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,19.19,,5.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,50,,15.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,31.35,
OPTIHALER SPACER FOR MDI,25109815,CDM,250,RC,,,Outpatient,,,118,118,,,,,,Other,Not Separately Reimbursable,97.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,97.35,82.5,,77.88,percent of total billed charges,Pays at 82.5% of total Billed charges,86.14,73,,68.912,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.6,70,,66.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,19.19,,18.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59,50,,47.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,97.35,
VECURONIUM(NORCURON)INJ:10MG,25109825,CDM,250,RC,,,Outpatient,,,82,82,,,,,,Other,Not Separately Reimbursable,67.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,67.65,82.5,,54.12,percent of total billed charges,Pays at 82.5% of total Billed charges,59.86,73,,47.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.4,70,,45.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,19.19,,12.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41,50,,32.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,67.65,
NITROPRUSSIDE SOD INJ: 50 MG,25109855,CDM,250,RC,,,Outpatient,,,2707,2707,,,,,,Other,Not Separately Reimbursable,2233.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2233.28,82.5,,1786.624,percent of total billed charges,Pays at 82.5% of total Billed charges,1976.11,73,,1580.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1894.9,70,,1515.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,519.47,19.19,,415.576,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1353.5,50,,1082.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,519.47,2233.28,
SOD CIT/CIT ACID (BICITRA/SHOALS) :30ML,25109860,CDM,250,RC,90675,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
RABIES VACCINE:1 ML,25109885,CDM,636,RC,90375,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
RABIES IMMUNE GLOBULIN,25109895,CDM,636,RC,,,Outpatient,,,2580,2580,,,,,,Other,Not Separately Reimbursable,2128.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2128.5,82.5,,1702.8,percent of total billed charges,Pays at 82.5% of total Billed charges,1883.4,73,,1506.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1806,70,,1444.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,495.1,19.19,,396.08,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1290,50,,1032,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,495.1,2128.5,
MIVACRON (MIVACURIUM) INJ : 10MG/5ML,25109905,CDM,250,RC,J2792,HCPCS,Outpatient,,,349,349,,,,,,Other,Not Separately Reimbursable,287.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,287.93,82.5,,230.344,percent of total billed charges,Pays at 82.5% of total Billed charges,254.77,73,,203.816,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,244.3,70,,195.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.97,19.19,,53.576,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.5,50,,139.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.97,287.93,
RHO(D)IMMUNE GLOBULIN:1500 IU(300 MCG),25109940,CDM,636,RC,,,Outpatient,,,2666,2666,,,,,,Other,Not Separately Reimbursable,2199.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2199.45,82.5,,1759.56,percent of total billed charges,Pays at 82.5% of total Billed charges,1946.18,73,,1556.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1866.2,70,,1492.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,511.61,19.19,,409.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1333,50,,1066.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,511.61,2199.45,
BETADINE 5% OPHTH PREP 30 ML,25109955,CDM,250,RC,,,Outpatient,,,37,37,,,,,,Other,Not Separately Reimbursable,30.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,30.53,82.5,,24.424,percent of total billed charges,Pays at 82.5% of total Billed charges,27.01,73,,21.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.9,70,,20.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,19.19,,5.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.5,50,,14.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,30.53,
PHENYLEPHRINE NASAL SPRAY:0.5%,25109960,CDM,250,RC,,,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,31.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,31.35,82.5,,25.08,percent of total billed charges,Pays at 82.5% of total Billed charges,27.74,73,,22.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.6,70,,21.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,19.19,,5.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,50,,15.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,31.35,
NEO-SYNEPHRINE(phenylep)NASAL DROP:1%,25109961,CDM,250,RC,J1980,HCPCS,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,15.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,15.68,82.5,,12.544,percent of total billed charges,Pays at 82.5% of total Billed charges,13.87,73,,11.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.3,70,,10.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,19.19,,2.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.5,50,,7.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,15.68,
LEVSIN (HYOSCYAMINE) INJ:0.5MG/ML,25110015,CDM,250,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
VIGAMOX(MOXIFLOXACIN)OPHTH SOLN: 3 ML,25110020,CDM,250,RC,Q0138,HCPCS,Outpatient,,,260,260,,,,,,Other,Not Separately Reimbursable,214.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,214.5,82.5,,171.6,percent of total billed charges,Pays at 82.5% of total Billed charges,189.8,73,,151.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182,70,,145.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,19.19,,39.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,130,50,,104,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,214.5,
FERAHEME(FERUMOXYTOL) INJ: 510 MG,25110025,CDM,636,RC,,,Outpatient,,,4750,4750,,,,,,Other,Not Separately Reimbursable,3918.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3918.75,82.5,,3135,percent of total billed charges,Pays at 82.5% of total Billed charges,3467.5,73,,2774,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3325,70,,2660,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,911.53,19.19,,729.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2375,50,,1900,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,911.53,3918.75,
BREVITAL (METHOHEXITAL) INJ: 100 MG,25110120,CDM,250,RC,,,Outpatient,,,41,41,,,,,,Other,Not Separately Reimbursable,33.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33.83,82.5,,27.064,percent of total billed charges,Pays at 82.5% of total Billed charges,29.93,73,,23.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.7,70,,22.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,19.19,,6.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.5,50,,16.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,33.83,
SILVADENE(SILVER SULFADIAZENE)CREAM: 25G,25110170,CDM,250,RC,J2060,HCPCS,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,14.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.85,82.5,,11.88,percent of total billed charges,Pays at 82.5% of total Billed charges,13.14,73,,10.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,70,,10.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,19.19,,2.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9,50,,7.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,14.85,
LORazepam(ATIVAN)INJ:2MG/ML,25110200,CDM,250,RC,J2060,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ATIVAN(LORAZEPAM) DRIP 1 MG/ML,25110202,CDM,250,RC,J2060,HCPCS,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
ATIVAN(LORAZEPAM) DRIP 0.2 MG/ML,25110203,CDM,250,RC,J0278,HCPCS,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
AMIKACIN INJ:1GM/4ML,25110210,CDM,636,RC,,,Outpatient,,,126,126,,,,,,Other,Not Separately Reimbursable,103.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,103.95,82.5,,83.16,percent of total billed charges,Pays at 82.5% of total Billed charges,91.98,73,,73.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.2,70,,70.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.18,19.19,,19.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,50,,50.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.18,103.95,
BACTROBAN(MUPIROCIN)OINT:2%,25110270,CDM,250,RC,,,Outpatient,,,7,7,,,,,,Other,Not Separately Reimbursable,5.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5.78,82.5,,4.624,percent of total billed charges,Pays at 82.5% of total Billed charges,5.11,73,,4.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.9,70,,3.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,19.19,,1.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,50,,2.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,5.78,
DILTIAZEM CD(CARDIZEM)CAP:120MG,25110420,CDM,250,RC,J2997,HCPCS,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
ALTEPLASE (ACTIVASE)INJ: 50 MG,25110430,CDM,636,RC,J0561,HCPCS,Outpatient,,,10877,10877,,,,,,Other,Not Separately Reimbursable,8973.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8973.53,82.5,,7178.824,percent of total billed charges,Pays at 82.5% of total Billed charges,7940.21,73,,6352.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7613.9,70,,6091.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2087.3,19.19,,1669.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5438.5,50,,4350.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2087.3,8973.53,
BICILLIN LA INJ:1.2MU,25110505,CDM,250,RC,,,Outpatient,,,1134,1134,,,,,,Other,Not Separately Reimbursable,935.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,935.55,82.5,,748.44,percent of total billed charges,Pays at 82.5% of total Billed charges,827.82,73,,662.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,793.8,70,,635.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,217.61,19.19,,174.088,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,567,50,,453.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,217.61,935.55,
amLODIPine(NORVASC)TAB:5MG,25110680,CDM,250,RC,J3230,HCPCS,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,14.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.85,82.5,,11.88,percent of total billed charges,Pays at 82.5% of total Billed charges,13.14,73,,10.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,70,,10.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,19.19,,2.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9,50,,7.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,14.85,
CHLORPROMAZINE(THORAZINE)INJ:25MG,25110730,CDM,250,RC,,,Outpatient,,,211,211,,,,,,Other,Not Separately Reimbursable,5.23,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,5.23,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,154.03,73,,123.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147.7,70,,118.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.49,19.19,,32.392,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.5,50,,84.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.23,154.03,
amLODIPine(NORVASC)TAB:10MG,25110770,CDM,250,RC,,,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,7.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,7.43,82.5,,5.944,percent of total billed charges,Pays at 82.5% of total Billed charges,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,7.43,
MINERAL OIL 30ML:,25110785,CDM,250,RC,,,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
LEVOFLOXACIN(LEVAQUIN)TAB:250MG,25110885,CDM,250,RC,,,Outpatient,,,79,79,,,,,,Other,Not Separately Reimbursable,65.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,65.18,82.5,,52.144,percent of total billed charges,Pays at 82.5% of total Billed charges,57.67,73,,46.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.3,70,,44.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,19.19,,12.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.5,50,,31.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,65.18,
NTG(NITROGLYCERIN TRANSDERMAL):0.4MG/HR,25110960,CDM,250,RC,,,Outpatient,,,16,16,,,,,,Other,Not Separately Reimbursable,13.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13.2,82.5,,10.56,percent of total billed charges,Pays at 82.5% of total Billed charges,11.68,73,,9.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.2,70,,8.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,19.19,,2.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8,50,,6.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,13.2,
PREDNISONE 10MG TAB,25111180,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
PROPOFOL(DIPRIVAN)INJ:20ML,25111370,CDM,250,RC,,,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,26.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,26.4,82.5,,21.12,percent of total billed charges,Pays at 82.5% of total Billed charges,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,26.4,
PROPOFOL(DIPRIVAN)INJ:100ML,25111371,CDM,250,RC,J7608,HCPCS,Outpatient,,,144,144,,,,,,Other,Not Separately Reimbursable,118.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,118.8,82.5,,95.04,percent of total billed charges,Pays at 82.5% of total Billed charges,105.12,73,,84.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.8,70,,80.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.63,19.19,,22.104,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72,50,,57.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.63,118.8,
MUCOMYST(ACETYLCYSTEINE)SOL 20%:10ML,25111470,CDM,250,RC,,,Outpatient,,,96,96,,,,,,Other,Not Separately Reimbursable,79.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,79.2,82.5,,63.36,percent of total billed charges,Pays at 82.5% of total Billed charges,70.08,73,,56.064,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.2,70,,53.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,19.19,,14.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48,50,,38.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,79.2,
FLUCONAZOLE (DIFLUCAN) TAB: 150 MG,25111480,CDM,250,RC,J1956,HCPCS,Outpatient,,,112,112,,,,,,Other,Not Separately Reimbursable,92.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,92.4,82.5,,73.92,percent of total billed charges,Pays at 82.5% of total Billed charges,81.76,73,,65.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.4,70,,62.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,19.19,,17.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,50,,44.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,92.4,
LEVOFLOXACIN(LEVAQUIN)INJ:250MG/50ML,25111655,CDM,250,RC,J1956,HCPCS,Outpatient,,,145,145,,,,,,Other,Not Separately Reimbursable,119.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,119.63,82.5,,95.704,percent of total billed charges,Pays at 82.5% of total Billed charges,105.85,73,,84.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.5,70,,81.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.83,19.19,,22.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.5,50,,58,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.83,119.63,
LEVOFLOXACIN(LEVAQUIN)INJ:500MG/100ML,25111660,CDM,250,RC,J1956,HCPCS,Outpatient,,,167,167,,,,,,Other,Not Separately Reimbursable,137.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,137.78,82.5,,110.224,percent of total billed charges,Pays at 82.5% of total Billed charges,121.91,73,,97.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.9,70,,93.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,19.19,,25.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.5,50,,66.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,137.78,
LEVOFLOXACIN(LEVAQUIN)INJ:750MG/150ML,25111665,CDM,250,RC,,,Outpatient,,,250,250,,,,,,Other,Not Separately Reimbursable,206.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,206.25,82.5,,165,percent of total billed charges,Pays at 82.5% of total Billed charges,182.5,73,,146,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,70,,140,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,19.19,,38.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125,50,,100,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,206.25,
CELECOXIB(CELEBREX)CAP:100MG,25111775,CDM,250,RC,,,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,38.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,38.78,82.5,,31.024,percent of total billed charges,Pays at 82.5% of total Billed charges,34.31,73,,27.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.9,70,,26.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,19.19,,7.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.5,50,,18.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,38.78,
CELEBREX (CELECOXIB) CAP: 200 MG,25111780,CDM,250,RC,,,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,9.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.08,82.5,,7.264,percent of total billed charges,Pays at 82.5% of total Billed charges,8.03,73,,6.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.7,70,,6.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,19.19,,1.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.5,50,,4.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,9.08,
DECADRON(DEXAMETHASONE)ELIX:0.5MG/5ML,25112120,CDM,250,RC,J3030,HCPCS,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
SUMATRIPTAN(IMITREX)INJ 6MG:0.5ML,25112430,CDM,636,RC,,,Outpatient,,,490,490,,,,,,Other,Not Separately Reimbursable,404.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,404.25,82.5,,323.4,percent of total billed charges,Pays at 82.5% of total Billed charges,357.7,73,,286.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,343,70,,274.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.03,19.19,,75.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245,50,,196,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.03,404.25,
PAROXETINE(PAXIL)TAB:20MG,25112560,CDM,250,RC,,,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,23.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.1,82.5,,18.48,percent of total billed charges,Pays at 82.5% of total Billed charges,20.44,73,,16.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.6,70,,15.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,19.19,,4.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,50,,11.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,23.1,
oxyCODONE TAB:5MG,25112645,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
IBUPROFEN(MOTRIN)TAB:200MG,25112720,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
NTG(NITROGLYCERIN PATCH):0.2MG/HR,25113010,CDM,250,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
POTASSIUM PHOSPHATE INJ:15MM/5 ML,25113080,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
POTASSIUM PHOSPHATE 15mM IN 250 ML NS,25113081,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
NICOTINE(NICODERM)PATCH:14MG,25113130,CDM,250,RC,,,Outpatient,,,22,22,,,,,,Other,Not Separately Reimbursable,18.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.15,82.5,,14.52,percent of total billed charges,Pays at 82.5% of total Billed charges,16.06,73,,12.848,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.4,70,,12.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,19.19,,3.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11,50,,8.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,18.15,
AUGMENTIN(AMOX/CLAV)SUSP 400MG:5ML,25113151,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
AMOXICILLIN 125MG/5ML:1ML,25113175,CDM,250,RC,,,Outpatient,,,1,1,,,,,,Other,Not Separately Reimbursable,0.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,0.83,82.5,,0.664,percent of total billed charges,Pays at 82.5% of total Billed charges,0.73,73,,0.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.7,70,,0.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.19,19.19,,0.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.5,50,,0.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.19,0.83,
ACTIDOSE/SORBITOL:25GM,25113200,CDM,250,RC,S0077,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CLINDAMYCIN(CLEOCIN)INJ:900MG,25113380,CDM,250,RC,,,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
FENTANYL(DURAGESIC)PATCH:50MCG/HR,25113470,CDM,250,RC,90686,HCPCS,Outpatient,,,185,185,,,,,,Other,Not Separately Reimbursable,152.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,152.63,82.5,,122.104,percent of total billed charges,Pays at 82.5% of total Billed charges,135.05,73,,108.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,129.5,70,,103.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,19.19,,28.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.5,50,,74,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,152.63,
Flu shot-high dose for 2019-2020 flu season given by injection for people >65,25113480,CDM,636,RC,90732,HCPCS,Outpatient,,,165,165,,,,,,Other,Not Separately Reimbursable,136.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,136.13,82.5,,108.904,percent of total billed charges,Pays at 82.5% of total Billed charges,120.45,73,,96.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.5,70,,92.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.66,19.19,,25.328,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.5,50,,66,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.66,136.13,
pneumococcal Pneumococcal vaccine,25113485,CDM,636,RC,J2690,HCPCS,Outpatient,,,474,474,,,,,,Other,Not Separately Reimbursable,391.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,391.05,82.5,,312.84,percent of total billed charges,Pays at 82.5% of total Billed charges,346.02,73,,276.816,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,331.8,70,,265.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.96,19.19,,72.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,237,50,,189.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.96,391.05,
PROCAINAMIDE INJ: 1GM,25113520,CDM,636,RC,J2690,HCPCS,Outpatient,,,39,39,,,,,,Other,Not Separately Reimbursable,32.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,32.18,82.5,,25.744,percent of total billed charges,Pays at 82.5% of total Billed charges,28.47,73,,22.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.3,70,,21.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,19.19,,5.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.5,50,,15.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,32.18,
PROCAINAMIDE DRIP 4 GM/500 ML NS,25113521,CDM,636,RC,,,Outpatient,,,39,39,,,,,,Other,Not Separately Reimbursable,32.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,32.18,82.5,,25.744,percent of total billed charges,Pays at 82.5% of total Billed charges,28.47,73,,22.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.3,70,,21.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,19.19,,5.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.5,50,,15.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,32.18,
SOD BICARB 8.4% 10ML INJ,25113530,CDM,250,RC,,,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
SOD BICARB 4.2% 10ML SYR,25113535,CDM,250,RC,,,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,15.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,15.68,82.5,,12.544,percent of total billed charges,Pays at 82.5% of total Billed charges,13.87,73,,11.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.3,70,,10.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,19.19,,2.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.5,50,,7.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,15.68,
SOD BICARB 4.2%VIAL:5ML,25113536,CDM,250,RC,,,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,25.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,25.58,82.5,,20.464,percent of total billed charges,Pays at 82.5% of total Billed charges,22.63,73,,18.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.7,70,,17.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,19.19,,4.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.5,50,,12.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,25.58,
ISUPREL(ISOPROTERENOL)INJ:1MG,25113550,CDM,250,RC,J3475,HCPCS,Outpatient,,,39,39,,,,,,Other,Not Separately Reimbursable,32.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,32.18,82.5,,25.744,percent of total billed charges,Pays at 82.5% of total Billed charges,28.47,73,,22.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.3,70,,21.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,19.19,,5.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.5,50,,15.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,32.18,
MAGNESIUM SULFATE 50% 1GM:2ML,25113566,CDM,636,RC,J3475,HCPCS,Outpatient,,,112,112,,,,,,Other,Not Separately Reimbursable,92.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,92.4,82.5,,73.92,percent of total billed charges,Pays at 82.5% of total Billed charges,81.76,73,,65.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.4,70,,62.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,19.19,,17.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,50,,44.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,92.4,
MAGNESIUM SULF INJ:4 GM/8 ML,25113568,CDM,636,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
STERILE WATER: 10 ML VIAL,25113570,CDM,250,RC,,,Outpatient,,,2,2,,,,,,Other,Not Separately Reimbursable,1.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1.65,82.5,,1.32,percent of total billed charges,Pays at 82.5% of total Billed charges,1.46,73,,1.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.4,70,,1.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.38,19.19,,0.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1,50,,0.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.38,1.65,
SALINE INJ FOR DILUTION:10ML VIAL,25113580,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
CYANIDE ANTIDOTE KIT,25113770,CDM,250,RC,J0895,HCPCS,Outpatient,,,1140,1140,,,,,,Other,Not Separately Reimbursable,940.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,940.5,82.5,,752.4,percent of total billed charges,Pays at 82.5% of total Billed charges,832.2,73,,665.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,798,70,,638.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,218.77,19.19,,175.016,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,570,50,,456,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,218.77,940.5,
DEFEROXAMINE(DESFERAL)INJ:500MG,25113780,CDM,250,RC,J0470,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
BAL IN OIL(DIMERCAPROL)INJ:100MG/ML,25113790,CDM,636,RC,,,Outpatient,,,177,177,,,,,,Other,Not Separately Reimbursable,146.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,146.03,82.5,,116.824,percent of total billed charges,Pays at 82.5% of total Billed charges,129.21,73,,103.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,123.9,70,,99.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.97,19.19,,27.176,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.5,50,,70.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.97,146.03,
FLUMAZENIL(ROMAZICON)INJ:0.5MG/5ML,25113800,CDM,250,RC,Q9968,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
METHYLENE BLUE 10MG/ML:10ML,25113810,CDM,250,RC,J2730,HCPCS,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
PROTOPAM (PRALIDOXIME) INJ : 1GM,25113830,CDM,636,RC,J1644,HCPCS,Outpatient,,,361,361,,,,,,Other,Not Separately Reimbursable,297.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,297.83,82.5,,238.264,percent of total billed charges,Pays at 82.5% of total Billed charges,263.53,73,,210.824,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.7,70,,202.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.28,19.19,,55.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.5,50,,144.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.28,297.83,
"HEPARIN DRIP:25,000 UNITS",25113880,CDM,250,RC,J2810,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
THEOPHYLLINE DRIP:1.6MG/ML,25113890,CDM,250,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
LORATADINE(CLARITIN)TAB:10MG,25113900,CDM,250,RC,,,Outpatient,,,7,7,,,,,,Other,Not Separately Reimbursable,5.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5.78,82.5,,4.624,percent of total billed charges,Pays at 82.5% of total Billed charges,5.11,73,,4.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.9,70,,3.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,19.19,,1.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,50,,2.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,5.78,
CLARITIN(LORATADINE)SYR:5ML,25113905,CDM,250,RC,,,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,7.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,7.43,82.5,,5.944,percent of total billed charges,Pays at 82.5% of total Billed charges,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,7.43,
DAKIN SOLN HALF STRENGTH:473ML,25113970,CDM,250,RC,,,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,31.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,31.35,82.5,,25.08,percent of total billed charges,Pays at 82.5% of total Billed charges,27.74,73,,22.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.6,70,,21.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,19.19,,5.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,50,,15.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,31.35,
PRAVASTATIN(PRAVACHOL)TAB:20MG,25114150,CDM,250,RC,J1250,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,27.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.23,82.5,,21.784,percent of total billed charges,Pays at 82.5% of total Billed charges,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,27.23,
DOBUTAMINE INJ: 500 MG IN 250 ML D5W,25114190,CDM,250,RC,,,Outpatient,,,124,124,,,,,,Other,Not Separately Reimbursable,102.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,102.3,82.5,,81.84,percent of total billed charges,Pays at 82.5% of total Billed charges,90.52,73,,72.416,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.8,70,,69.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,19.19,,19.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62,50,,49.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,102.3,
DEPAKENE(VALPROIC ACID)SYRUP:250MG/5ML,25114220,CDM,250,RC,,,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
SALINE (OCEAN)NASAL:,25114230,CDM,250,RC,,,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,7.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,7.43,82.5,,5.944,percent of total billed charges,Pays at 82.5% of total Billed charges,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,7.43,
ZOLPIDEM(AMBIEN)TAB:10MG,25114240,CDM,250,RC,,,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,38.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,38.78,82.5,,31.024,percent of total billed charges,Pays at 82.5% of total Billed charges,34.31,73,,27.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.9,70,,26.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,19.19,,7.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.5,50,,18.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,38.78,
MYDRIN(PHENYLEPHRINE) OPHTH SOLN : 2.5%,25114350,CDM,250,RC,,,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,14.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.85,82.5,,11.88,percent of total billed charges,Pays at 82.5% of total Billed charges,13.14,73,,10.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,70,,10.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,19.19,,2.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9,50,,7.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,14.85,
NEOSYNEPHRINE 10%(AK DILATE)OPTH : 2.5%,25114351,CDM,250,RC,J2150,HCPCS,Outpatient,,,26,26,,,,,,Other,Not Separately Reimbursable,21.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,21.45,82.5,,17.16,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,73,,15.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.2,70,,14.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,19.19,,3.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13,50,,10.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,21.45,
MANNITOL INJ 50ML:25%,25114410,CDM,250,RC,S0020,HCPCS,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
MARCAINE(BUPIVICAINE)MPF 30ML:0.5%,25114520,CDM,250,RC,,,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,26.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,26.4,82.5,,21.12,percent of total billed charges,Pays at 82.5% of total Billed charges,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,26.4,
LIDOCAINE 4% 5ML INJ,25114530,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
BSS OPTH.IRRIGATION: 500ML,25114556,CDM,250,RC,90746,HCPCS,Outpatient,,,83,83,,,,,,Other,Not Separately Reimbursable,68.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,68.48,82.5,,54.784,percent of total billed charges,Pays at 82.5% of total Billed charges,60.59,73,,48.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.1,70,,46.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.93,19.19,,12.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.5,50,,33.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.93,68.48,
Hepatitis B vaccine,25114790,CDM,636,RC,J0743,HCPCS,Outpatient,,,188,188,,,,,,Other,Not Separately Reimbursable,155.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,155.1,82.5,,124.08,percent of total billed charges,Pays at 82.5% of total Billed charges,137.24,73,,109.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,131.6,70,,105.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.08,19.19,,28.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94,50,,75.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.08,155.1,
IMIPENEM/CILASTIN (PRIMAXIN) INJ: 250MG,25117030,CDM,250,RC,J0743,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
IMIPENEM/CILASTIN (PRIMAXIN) INJ: 500MG,25117035,CDM,250,RC,,,Outpatient,,,210,210,,,,,,Other,Not Separately Reimbursable,173.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,173.25,82.5,,138.6,percent of total billed charges,Pays at 82.5% of total Billed charges,153.3,73,,122.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,70,,117.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,19.19,,32.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,50,,84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,173.25,
RONDEC DM LIQ : 5ML,25117060,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
ZOLPIDEM(AMBIEN)TAB:5MG,25118060,CDM,250,RC,,,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,38.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,38.78,82.5,,31.024,percent of total billed charges,Pays at 82.5% of total Billed charges,34.31,73,,27.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.9,70,,26.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,19.19,,7.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.5,50,,18.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,38.78,
LACTINEX(LACTOBACILLUS) TAB,25118100,CDM,250,RC,,,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
LACTOBACILLUS(FLORANEX)GRANULES:1 PKT,25118105,CDM,250,RC,,,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
NYSTATIN CREAM 15 GM,25118170,CDM,250,RC,,,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
MYCOSTATIN(NYSTATIN)POWDER:15 GM,25118175,CDM,250,RC,,,Outpatient,,,115,115,,,,,,Other,Not Separately Reimbursable,94.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,94.88,82.5,,75.904,percent of total billed charges,Pays at 82.5% of total Billed charges,83.95,73,,67.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.5,70,,64.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.07,19.19,,17.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.5,50,,46,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.07,94.88,
FENTANYL(DURAGESIC)PATCH:25MCG/HR,25118190,CDM,250,RC,,,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
PEPTO-BISMOL(BISMUTH)LIQ:4OZ,25118250,CDM,250,RC,J2405,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,9.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.9,82.5,,7.92,percent of total billed charges,Pays at 82.5% of total Billed charges,8.76,73,,7.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.4,70,,6.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,19.19,,1.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6,50,,4.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,9.9,
ONDANSETRON(ZOFRAN)INJ:4MG,25118275,CDM,636,RC,,,Outpatient,,,333,333,,,,,,Other,Not Separately Reimbursable,274.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,274.73,82.5,,219.784,percent of total billed charges,Pays at 82.5% of total Billed charges,243.09,73,,194.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,233.1,70,,186.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.9,19.19,,51.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.5,50,,133.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.9,274.73,
HYDROCORTISONE(ANUSOL HC)SUPP:25MG,25118310,CDM,250,RC,,,Outpatient,,,159,159,,,,,,Other,Not Separately Reimbursable,131.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,131.18,82.5,,104.944,percent of total billed charges,Pays at 82.5% of total Billed charges,116.07,73,,92.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.3,70,,89.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.51,19.19,,24.408,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.5,50,,63.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.51,131.18,
NORepinephrine(LEVOPHED)INJ:4MG/ML,25118400,CDM,250,RC,,,Outpatient,,,118,118,,,,,,Other,Not Separately Reimbursable,97.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,97.35,82.5,,77.88,percent of total billed charges,Pays at 82.5% of total Billed charges,86.14,73,,68.912,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.6,70,,66.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,19.19,,18.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59,50,,47.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,97.35,
CYCLOGEL(CYCLOPENTOLATE):1%,25118540,CDM,250,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ISOSORBIDE MONO(IMDUR)TAB:30MG,25118555,CDM,250,RC,,,Outpatient,,,17,17,,,,,,Other,Not Separately Reimbursable,14.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.03,82.5,,11.224,percent of total billed charges,Pays at 82.5% of total Billed charges,12.41,73,,9.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,70,,9.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.26,19.19,,2.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.5,50,,6.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.26,14.03,
IMDUR(ISOSORBIDE MONO)TAB:60MG,25118560,CDM,250,RC,,,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
"BACITRACIN POWDER 50,000 UNITS",25118650,CDM,250,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
VERAPAMIL INJ:5MG,25118690,CDM,250,RC,,,Outpatient,,,251,251,,,,,,Other,Not Separately Reimbursable,207.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,207.08,82.5,,165.664,percent of total billed charges,Pays at 82.5% of total Billed charges,183.23,73,,146.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175.7,70,,140.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.17,19.19,,38.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125.5,50,,100.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.17,207.08,
CORTISPORIN OPTH OINT:3.5GM,25118720,CDM,250,RC,,,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,43.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,43.73,82.5,,34.984,percent of total billed charges,Pays at 82.5% of total Billed charges,38.69,73,,30.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.1,70,,29.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,19.19,,8.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.5,50,,21.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,43.73,
NEO-DECADRON OPHTH OINT : 3.5GM,25118750,CDM,250,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
MORPHINE SOLN.CONC: 20MG/1ML,25118860,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
MORPHINE SOLN.CONC.:20 MG/ML,25118861,CDM,250,RC,,,Outpatient,,,16,16,,,,,,Other,Not Separately Reimbursable,13.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13.2,82.5,,10.56,percent of total billed charges,Pays at 82.5% of total Billed charges,11.68,73,,9.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.2,70,,8.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,19.19,,2.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8,50,,6.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,13.2,
PREVACID(LANSOPRAZOLE)SOLUTAB:15 MG,25118865,CDM,250,RC,,,Outpatient,,,27,27,,,,,,Other,Not Separately Reimbursable,22.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,22.28,82.5,,17.824,percent of total billed charges,Pays at 82.5% of total Billed charges,19.71,73,,15.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.9,70,,15.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,19.19,,4.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.5,50,,10.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,22.28,
PROPARACAINE OPHTH SOLN:0.5%,25118880,CDM,250,RC,,,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,26.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,26.4,82.5,,21.12,percent of total billed charges,Pays at 82.5% of total Billed charges,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,26.4,
glipiZIDE XL(GLUCOTROL XL)TAB:5MG,25118950,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
GLIPIZIDE XL(GLUCOTROL XL)TAB:2.5MG,25118960,CDM,250,RC,J1750,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DEXFERRUM(IRON DEXTRAN FOR IV) 50MG:1ML,25119030,CDM,250,RC,J1750,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
INFED (IRON DEXTRAN ):50 MG,25119031,CDM,636,RC,J1756,HCPCS,Outpatient,,,126,126,,,,,,Other,Not Separately Reimbursable,103.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,103.95,82.5,,83.16,percent of total billed charges,Pays at 82.5% of total Billed charges,91.98,73,,73.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.2,70,,70.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.18,19.19,,19.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,50,,50.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.18,103.95,
VENOFER(IRON SUCROSE)INJ:100MG,25119035,CDM,636,RC,,,Outpatient,,,480,480,,,,,,Other,Not Separately Reimbursable,396,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,396,82.5,,316.8,percent of total billed charges,Pays at 82.5% of total Billed charges,350.4,73,,280.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,336,70,,268.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.11,19.19,,73.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,240,50,,192,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.11,396,
KETALAR(KETAMINE)INJ:100MG/ML,25119040,CDM,250,RC,,,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
KETAMINE INJ 50MG/ML:1ML,25119041,CDM,250,RC,S0020,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
MARCAINE (BUPIVICAINE) PF VIAL:0.5% 10ML,25119050,CDM,250,RC,J2560,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,26.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,26.4,82.5,,21.12,percent of total billed charges,Pays at 82.5% of total Billed charges,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,26.4,
PHENOBARBITAL INJ 65MG:1ML,25119060,CDM,250,RC,,,Outpatient,,,154,154,,,,,,Other,Not Separately Reimbursable,16.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,16.1,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,112.42,73,,89.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.8,70,,86.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.55,19.19,,23.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,50,,61.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.1,112.42,
PREDNISOLONE(PRELONE)LIQ:15MG/5ML,25119130,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
GABAPENTIN(NEURONTIN)CAP:300MG,25119140,CDM,250,RC,,,Outpatient,,,17,17,,,,,,Other,Not Separately Reimbursable,14.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.03,82.5,,11.224,percent of total billed charges,Pays at 82.5% of total Billed charges,12.41,73,,9.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,70,,9.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.26,19.19,,2.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.5,50,,6.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.26,14.03,
GABAPENTIN(NEURONTIN)CAP:400MG,25119145,CDM,250,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
VENLAFAXINE XR(EFFEXOR)CAP:75MG,25119155,CDM,250,RC,,,Outpatient,,,41,41,,,,,,Other,Not Separately Reimbursable,33.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33.83,82.5,,27.064,percent of total billed charges,Pays at 82.5% of total Billed charges,29.93,73,,23.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.7,70,,22.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,19.19,,6.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.5,50,,16.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,33.83,
NEURONTIN(GABAPENTIN):600MG,25119160,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CALCIUM CHLORIDE 10%:10ML SYR,25119220,CDM,250,RC,,,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,23.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.1,82.5,,18.48,percent of total billed charges,Pays at 82.5% of total Billed charges,20.44,73,,16.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.6,70,,15.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,19.19,,4.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,50,,11.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,23.1,
CALCIUM CHLORIDE 2 GM IN 250 ML,25119221,CDM,250,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
BUMETANIDE 0.25MG/ML INJ:10ML,25119250,CDM,250,RC,J1440,HCPCS,Outpatient,,,26,26,,,,,,Other,Not Separately Reimbursable,21.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,21.45,82.5,,17.16,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,73,,15.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.2,70,,14.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,19.19,,3.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13,50,,10.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,21.45,
NEUPOGEN:300MCG/0.5ML,25119290,CDM,636,RC,J1442,HCPCS,Outpatient,,,1557,1557,,,,,,Other,Not Separately Reimbursable,1284.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1284.53,82.5,,1027.624,percent of total billed charges,Pays at 82.5% of total Billed charges,1136.61,73,,909.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1089.9,70,,871.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,298.79,19.19,,239.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,778.5,50,,622.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,298.79,1284.53,
NEUPOGEN: 480 MCG INJ,25119296,CDM,636,RC,,,Outpatient,,,2500,2500,,,,,,Other,Not Separately Reimbursable,2062.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2062.5,82.5,,1650,percent of total billed charges,Pays at 82.5% of total Billed charges,1825,73,,1460,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1750,70,,1400,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,479.75,19.19,,383.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1250,50,,1000,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,479.75,2062.5,
AMIODARONE(CORDARONE)TAB:200MG,25119340,CDM,250,RC,J0282,HCPCS,Outpatient,,,72,72,,,,,,Other,Not Separately Reimbursable,59.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,59.4,82.5,,47.52,percent of total billed charges,Pays at 82.5% of total Billed charges,52.56,73,,42.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.4,70,,40.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,19.19,,11.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36,50,,28.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,59.4,
CORDARONE (AMIODARONE)INJ:30 MG,25119345,CDM,250,RC,J0282,HCPCS,Outpatient,,,73,73,,,,,,Other,Not Separately Reimbursable,60.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,60.23,82.5,,48.184,percent of total billed charges,Pays at 82.5% of total Billed charges,53.29,73,,42.632,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.1,70,,40.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.01,19.19,,11.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.5,50,,29.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.01,60.23,
CORDARONE (AMIODARONE)INJ:450 MG,25119350,CDM,250,RC,J0282,HCPCS,Outpatient,,,371,371,,,,,,Other,Not Separately Reimbursable,306.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,306.08,82.5,,244.864,percent of total billed charges,Pays at 82.5% of total Billed charges,270.83,73,,216.664,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,259.7,70,,207.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.19,19.19,,56.952,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,185.5,50,,148.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.19,306.08,
AMIODARONE(CORDARONE)INJ:150MG,25119355,CDM,636,RC,,,Outpatient,,,105,105,,,,,,Other,Not Separately Reimbursable,86.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,86.63,82.5,,69.304,percent of total billed charges,Pays at 82.5% of total Billed charges,76.65,73,,61.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.5,70,,58.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,19.19,,16.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,50,,42,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,86.63,
ROCURONIUM(ZEMURON)INJ:50MG,25119360,CDM,250,RC,J3105,HCPCS,Outpatient,,,79,79,,,,,,Other,Not Separately Reimbursable,65.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,65.18,82.5,,52.144,percent of total billed charges,Pays at 82.5% of total Billed charges,57.67,73,,46.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.3,70,,44.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,19.19,,12.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.5,50,,31.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,65.18,
BRETHINE(TERBUTALINE)INJ:1MG,25119400,CDM,250,RC,,,Outpatient,,,8,8,,,,,,Other,Not Separately Reimbursable,6.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6.6,82.5,,5.28,percent of total billed charges,Pays at 82.5% of total Billed charges,5.84,73,,4.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.6,70,,4.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,19.19,,1.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4,50,,3.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,6.6,
SOTALOL(BETAPACE)TAB:80MG,25119420,CDM,250,RC,,,Outpatient,,,26,26,,,,,,Other,Not Separately Reimbursable,21.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,21.45,82.5,,17.16,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,73,,15.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.2,70,,14.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,19.19,,3.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13,50,,10.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,21.45,
IBUPROFEN(MOTRIN)LIQ:200MG/10 ML,25119440,CDM,250,RC,,,Outpatient,,,7,7,,,,,,Other,Not Separately Reimbursable,5.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5.78,82.5,,4.624,percent of total billed charges,Pays at 82.5% of total Billed charges,5.11,73,,4.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.9,70,,3.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,19.19,,1.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,50,,2.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,5.78,
METOPROLOL XL(TOPROL)TAB:50MG,25119465,CDM,250,RC,,,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,9.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.9,82.5,,7.92,percent of total billed charges,Pays at 82.5% of total Billed charges,8.76,73,,7.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.4,70,,6.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,19.19,,1.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6,50,,4.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,9.9,
METOPROLOL XL(TOPROL)TAB:25MG,25119466,CDM,250,RC,,,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,9.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.9,82.5,,7.92,percent of total billed charges,Pays at 82.5% of total Billed charges,8.76,73,,7.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.4,70,,6.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,19.19,,1.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6,50,,4.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,9.9,
metFORMIN(GLUCOPHAGE)TAB: 500MG,25119515,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
LIDOCAINE INJ: 2% W/ EPI 20ML,25119520,CDM,250,RC,,,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
ONDANSETRON(ZOFRAN)TAB:4MG,25119530,CDM,250,RC,,,Outpatient,,,174,174,,,,,,Other,Not Separately Reimbursable,143.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,143.55,82.5,,114.84,percent of total billed charges,Pays at 82.5% of total Billed charges,127.02,73,,101.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121.8,70,,97.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.39,19.19,,26.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87,50,,69.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.39,143.55,
ONDANSETRON(ZOFRAN)LIQ:2MG/2.5 ML,25119531,CDM,250,RC,J1120,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
ACETAZOLAMIDE(DIAMOX)INJ: 500 MG,25119535,CDM,250,RC,,,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
TRAMADOL(ULTRAM)TAB:50MG,25119540,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
OFLOXACIN(OCUFLOX)OPHTH SOLN:0.3% 5ML,25119665,CDM,250,RC,J3535,HCPCS,Outpatient,,,126,126,,,,,,Other,Not Separately Reimbursable,103.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,103.95,82.5,,83.16,percent of total billed charges,Pays at 82.5% of total Billed charges,91.98,73,,73.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.2,70,,70.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.18,19.19,,19.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,50,,50.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.18,103.95,
FLONASE(FLUTICASONE)NASAL INHALER:16GM,25119680,CDM,250,RC,,,Outpatient,,,427,427,,,,,,Other,Not Separately Reimbursable,352.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,352.28,82.5,,281.824,percent of total billed charges,Pays at 82.5% of total Billed charges,311.71,73,,249.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,298.9,70,,239.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.94,19.19,,65.552,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,213.5,50,,170.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.94,352.28,
XYLOCAINE(LIDOCAINE)MPF 2% INJ:5 ML,25119695,CDM,250,RC,S0179,HCPCS,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
MEGESTROL(MEGACE)40MG/ML LIQ:10ML,25119710,CDM,250,RC,S0039,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
SEPTRA(SULFAMETH/TRIMETH)INJ:10 ML,25119715,CDM,250,RC,,,Outpatient,,,43,43,,,,,,Other,Not Separately Reimbursable,35.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,35.48,82.5,,28.384,percent of total billed charges,Pays at 82.5% of total Billed charges,31.39,73,,25.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.1,70,,24.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,19.19,,6.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.5,50,,17.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,35.48,
LIDOCAINE:2% 20ML INJ,25119720,CDM,250,RC,,,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,47.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.03,82.5,,37.624,percent of total billed charges,Pays at 82.5% of total Billed charges,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,47.03,
CETIRIZINE(ZyrTEC)SYR:5MG/5ML,25119795,CDM,250,RC,,,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
CIPROFLOXACIN(CILOXAN)OS 0.3%: 5ML,25119800,CDM,250,RC,,,Outpatient,,,284,284,,,,,,Other,Not Separately Reimbursable,234.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,234.3,82.5,,187.44,percent of total billed charges,Pays at 82.5% of total Billed charges,207.32,73,,165.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,198.8,70,,159.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.5,19.19,,43.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,142,50,,113.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.5,234.3,
LOSARTAN(COZAAR)TAB: 50MG,25119810,CDM,250,RC,,,Outpatient,,,21,21,,,,,,Other,Not Separately Reimbursable,17.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,17.33,82.5,,13.864,percent of total billed charges,Pays at 82.5% of total Billed charges,15.33,73,,12.264,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.7,70,,11.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,19.19,,3.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,50,,8.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,17.33,
LOSARTAN(COZAAR)TAB: 25MG,25119811,CDM,250,RC,,,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,14.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.85,82.5,,11.88,percent of total billed charges,Pays at 82.5% of total Billed charges,13.14,73,,10.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,70,,10.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,19.19,,2.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9,50,,7.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,14.85,
LOSARTAN/HCTZ(HYZAAR)TAB: 50MG/12.5MG,25119815,CDM,250,RC,,,Outpatient,,,27,27,,,,,,Other,Not Separately Reimbursable,22.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,22.28,82.5,,17.824,percent of total billed charges,Pays at 82.5% of total Billed charges,19.71,73,,15.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.9,70,,15.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,19.19,,4.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.5,50,,10.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,22.28,
CEPHALEXIN(KEFLEX)SUSP125MG/5ML:5 ML,25119825,CDM,250,RC,J1450,HCPCS,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
FLUCONAZOLE(DIFLUCAN)200MG/100ML IVPB,25119855,CDM,250,RC,,,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,71.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,71.78,82.5,,57.424,percent of total billed charges,Pays at 82.5% of total Billed charges,63.51,73,,50.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.9,70,,48.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,19.19,,13.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.5,50,,34.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,71.78,
RISPERIDONE(RISPERDAL)TAB:1MG,25119885,CDM,250,RC,S0073,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
AZTREONAM(AZACTAM)INJ:1GM,25119890,CDM,250,RC,,,Outpatient,,,175,175,,,,,,Other,Not Separately Reimbursable,144.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,144.38,82.5,,115.504,percent of total billed charges,Pays at 82.5% of total Billed charges,127.75,73,,102.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.5,70,,98,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.58,19.19,,26.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,50,,70,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.58,144.38,
MACROBID(NITROFURANTION)CAP:100MG,25119910,CDM,250,RC,,,Outpatient,,,24,24,,,,,,Other,Not Separately Reimbursable,19.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,19.8,82.5,,15.84,percent of total billed charges,Pays at 82.5% of total Billed charges,17.52,73,,14.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.8,70,,13.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.61,19.19,,3.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12,50,,9.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.61,19.8,
HYDROCODONE 7.5MG/APAP 500MG(LORTAB)TAB,25119950,CDM,250,RC,S0073,HCPCS,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.5,50,,2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
AZACTAM(AZTREONAM)INJ:500MG,25119955,CDM,250,RC,,,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,25.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,25.58,82.5,,20.464,percent of total billed charges,Pays at 82.5% of total Billed charges,22.63,73,,18.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.7,70,,17.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,19.19,,4.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.5,50,,12.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,25.58,
MAXITROL(NEO/POLY/DEX)OPTH OINT:,25119965,CDM,250,RC,,,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
NITROLINGUAL (NTG) SPRAY : 0.4MG/SPRAY,25119985,CDM,250,RC,,,Outpatient,,,208,208,,,,,,Other,Not Separately Reimbursable,171.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,171.6,82.5,,137.28,percent of total billed charges,Pays at 82.5% of total Billed charges,151.84,73,,121.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,145.6,70,,116.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.92,19.19,,31.936,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104,50,,83.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.92,171.6,
CALCIUM WITH VIT D:500MG,25120020,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
MIRTAZAPINE(REMERON)TAB:15MG,25120025,CDM,250,RC,,,Outpatient,,,34,34,,,,,,Other,Not Separately Reimbursable,28.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.05,82.5,,22.44,percent of total billed charges,Pays at 82.5% of total Billed charges,24.82,73,,19.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,70,,19.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,19.19,,5.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17,50,,13.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,28.05,
BACLOFEN TAB:10MG,25120040,CDM,250,RC,Q2009,HCPCS,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,20.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,20.63,82.5,,16.504,percent of total billed charges,Pays at 82.5% of total Billed charges,18.25,73,,14.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,70,,14,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,19.19,,3.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,50,,10,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,20.63,
FOSPHENYTOIN(CEREBYX)INJ:50 MG,25120045,CDM,250,RC,J1265,HCPCS,Outpatient,,,36,36,,,,,,Other,Not Separately Reimbursable,29.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,29.7,82.5,,23.76,percent of total billed charges,Pays at 82.5% of total Billed charges,26.28,73,,21.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.2,70,,20.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,19.19,,5.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18,50,,14.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,29.7,
DOPAMINE PREMIX 3200MCG/ML:800MG/250ML,25130025,CDM,250,RC,,,Outpatient,,,202,202,,,,,,Other,Not Separately Reimbursable,166.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,166.65,82.5,,133.32,percent of total billed charges,Pays at 82.5% of total Billed charges,147.46,73,,117.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,141.4,70,,113.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.76,19.19,,31.008,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101,50,,80.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.76,166.65,
ALLEGRA (FEX0FENADINE) CAP: 60MG,25130040,CDM,250,RC,,,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
MAG-OX(MAGNESIUM OXIDE)TAB:400MG,25130050,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
LEVOFLOXACIN(LEVAQUIN)TAB:500MG,25130090,CDM,250,RC,,,Outpatient,,,135,135,,,,,,Other,Not Separately Reimbursable,111.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,111.38,82.5,,89.104,percent of total billed charges,Pays at 82.5% of total Billed charges,98.55,73,,78.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.5,70,,75.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.91,19.19,,20.728,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.5,50,,54,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.91,111.38,
DONEPEZIL(ARICEPT)TAB:5MG,25130115,CDM,250,RC,,,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
GLIMEPIRIDE(AMARYL)TAB:4MG,25130135,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
VOLTAREN(DICLOFENAC)OPTH SOLN:,25130145,CDM,250,RC,,,Outpatient,,,68,68,,,,,,Other,Not Separately Reimbursable,56.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.1,82.5,,44.88,percent of total billed charges,Pays at 82.5% of total Billed charges,49.64,73,,39.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.6,70,,38.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,19.19,,10.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34,50,,27.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,56.1,
K-PHOS NEUTRAL: 250MG,25130150,CDM,250,RC,S0106,HCPCS,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
BuPROPion XL(WELLBUTRIN)TAB: 150 MG,25130175,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
TOBRADEX(TOBRAMYCIN/DEX)OO 3.5GM:,25130200,CDM,250,RC,,,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,72.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,72.6,82.5,,58.08,percent of total billed charges,Pays at 82.5% of total Billed charges,64.24,73,,51.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,70,,49.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,19.19,,13.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44,50,,35.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,72.6,
GABAPENTIN(NEURONTIN)CAP:100MG,25130300,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CLOPIDOGREL(PLAVIX)TAB:75MG,25130335,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CARVEDILOL(COREG)TAB: 6.25MG,25130345,CDM,250,RC,,,Outpatient,,,22,22,,,,,,Other,Not Separately Reimbursable,18.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.15,82.5,,14.52,percent of total billed charges,Pays at 82.5% of total Billed charges,16.06,73,,12.848,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.4,70,,12.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,19.19,,3.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11,50,,8.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,18.15,
CARVEDILOL(COREG)TAB:12.5MG,25130350,CDM,250,RC,J1815,HCPCS,Outpatient,,,22,22,,,,,,Other,Not Separately Reimbursable,18.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.15,82.5,,14.52,percent of total billed charges,Pays at 82.5% of total Billed charges,16.06,73,,12.848,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.4,70,,12.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,19.19,,3.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11,50,,8.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,18.15,
HUMULIN/NOVOLIN NPH INSULIN,25130355,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
AMOXICILLIN/CLAV.(AUGMENTIN)TAB:875MG,25130380,CDM,250,RC,,,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
TAMSULOSIN(FLOMAX)CAP:0.4MG,25130390,CDM,250,RC,,,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,31.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,31.35,82.5,,25.08,percent of total billed charges,Pays at 82.5% of total Billed charges,27.74,73,,22.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.6,70,,21.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,19.19,,5.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,50,,15.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,31.35,
ENALAPRILAT(VASOTEC)INJ:1.25MG,25130405,CDM,250,RC,,,Outpatient,,,21,21,,,,,,Other,Not Separately Reimbursable,17.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,17.33,82.5,,13.864,percent of total billed charges,Pays at 82.5% of total Billed charges,15.33,73,,12.264,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.7,70,,11.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,19.19,,3.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,50,,8.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,17.33,
OLANZAPINE(ZYPREXA)OD TAB:5MG,25130420,CDM,250,RC,J0692,HCPCS,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,93.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,93.23,82.5,,74.584,percent of total billed charges,Pays at 82.5% of total Billed charges,82.49,73,,65.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.1,70,,63.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,19.19,,17.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.5,50,,45.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,93.23,
MAXIPIME (CEFEPIME) INJ : 500MG,25130430,CDM,250,RC,J1650,HCPCS,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,20.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,20.63,82.5,,16.504,percent of total billed charges,Pays at 82.5% of total Billed charges,18.25,73,,14.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,70,,14,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,19.19,,3.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,50,,10,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,20.63,
ENOXAPARIN(LOVENOX)INJ:30MG,25130445,CDM,250,RC,J1650,HCPCS,Outpatient,,,209,209,,,,,,Other,Not Separately Reimbursable,172.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,172.43,82.5,,137.944,percent of total billed charges,Pays at 82.5% of total Billed charges,152.57,73,,122.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,146.3,70,,117.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.11,19.19,,32.088,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.5,50,,83.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.11,172.43,
ENOXAPARIN(LOVENOX)INJ:40MG,25130450,CDM,250,RC,J1650,HCPCS,Outpatient,,,278,278,,,,,,Other,Not Separately Reimbursable,229.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,229.35,82.5,,183.48,percent of total billed charges,Pays at 82.5% of total Billed charges,202.94,73,,162.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,194.6,70,,155.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.35,19.19,,42.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139,50,,111.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.35,229.35,
ENOXAPARIN(LOVENOX)INJ:60MG,25130455,CDM,250,RC,J1650,HCPCS,Outpatient,,,358,358,,,,,,Other,Not Separately Reimbursable,295.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,295.35,82.5,,236.28,percent of total billed charges,Pays at 82.5% of total Billed charges,261.34,73,,209.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,250.6,70,,200.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.7,19.19,,54.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179,50,,143.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.7,295.35,
ENOXAPARIN(LOVENOX)INJ:80MG,25130460,CDM,250,RC,J1650,HCPCS,Outpatient,,,477,477,,,,,,Other,Not Separately Reimbursable,393.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,393.53,82.5,,314.824,percent of total billed charges,Pays at 82.5% of total Billed charges,348.21,73,,278.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,333.9,70,,267.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.54,19.19,,73.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,238.5,50,,190.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.54,393.53,
ENOXAPARIN(LOVENOX)INJ:100MG,25130465,CDM,250,RC,J0696,HCPCS,Outpatient,,,497,497,,,,,,Other,Not Separately Reimbursable,410.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,410.03,82.5,,328.024,percent of total billed charges,Pays at 82.5% of total Billed charges,362.81,73,,290.248,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,347.9,70,,278.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.37,19.19,,76.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,248.5,50,,198.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.37,410.03,
CEFTRIAXONE(ROCEPHIN)INJ:1GM,25150060,CDM,636,RC,J0696,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
CEFTRIAXONE(ROCEPHIN)INJ:2 GM ADD-VANT,25150070,CDM,636,RC,J3260,HCPCS,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
TOBRAMYCIN INJ:80MG,25150110,CDM,250,RC,J3260,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
TOBRAMYCIN 240 MG IN 100 ML NS,25150111,CDM,250,RC,J3260,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
TOBRAMYCIN 320 MG IN 100 ML NS,25150112,CDM,250,RC,J3260,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
TOBRAMYCIN 400 MG IN 100 ML NS,25150113,CDM,250,RC,J3260,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
TOBRAMYCIN 480 MG IN 100 ML NS,25150114,CDM,250,RC,J3260,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
TOBRAMYCIN 560 MG IN 100 ML NS,25150116,CDM,250,RC,S0040,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
TIMENTIN(TICARCILLIN/CLAV) INJ:3.1GM ADD,25150170,CDM,250,RC,S0077,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
CLINDAMYCIN(CLEOCIN)INJ:300MG ADDVANT,25150220,CDM,250,RC,S0077,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
CLINDAMYCIN(CLEOCIN)INJ:600MG ADDVANT,25150230,CDM,250,RC,J3370,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
VANCOMYCIN INJ:500MG,25150240,CDM,636,RC,J3370,HCPCS,Outpatient,,,67,67,,,,,,Other,Not Separately Reimbursable,55.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,55.28,82.5,,44.224,percent of total billed charges,Pays at 82.5% of total Billed charges,48.91,73,,39.128,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,70,,37.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,19.19,,10.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.5,50,,26.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.86,55.28,
VANCOCIN 1400 MG/250 ML NS,25150241,CDM,636,RC,J3370,HCPCS,Outpatient,,,167,167,,,,,,Other,Not Separately Reimbursable,137.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,137.78,82.5,,110.224,percent of total billed charges,Pays at 82.5% of total Billed charges,121.91,73,,97.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.9,70,,93.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,19.19,,25.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.5,50,,66.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,137.78,
VANCOCIN 1300 MG/250 ML NS,25150242,CDM,636,RC,J3370,HCPCS,Outpatient,,,167,167,,,,,,Other,Not Separately Reimbursable,137.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,137.78,82.5,,110.224,percent of total billed charges,Pays at 82.5% of total Billed charges,121.91,73,,97.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.9,70,,93.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,19.19,,25.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.5,50,,66.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,137.78,
VANCOCIN 1600 MG/250 ML NS,25150244,CDM,636,RC,J3370,HCPCS,Outpatient,,,167,167,,,,,,Other,Not Separately Reimbursable,137.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,137.78,82.5,,110.224,percent of total billed charges,Pays at 82.5% of total Billed charges,121.91,73,,97.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.9,70,,93.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,19.19,,25.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.5,50,,66.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,137.78,
VANCOMYCIN INJ:500 MG ADD-VANT,25150245,CDM,636,RC,J3370,HCPCS,Outpatient,,,41,41,,,,,,Other,Not Separately Reimbursable,33.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33.83,82.5,,27.064,percent of total billed charges,Pays at 82.5% of total Billed charges,29.93,73,,23.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.7,70,,22.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,19.19,,6.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.5,50,,16.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,33.83,
VANCOCIN 1700 MG/250 ML NS,25150246,CDM,636,RC,J3370,HCPCS,Outpatient,,,167,167,,,,,,Other,Not Separately Reimbursable,137.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,137.78,82.5,,110.224,percent of total billed charges,Pays at 82.5% of total Billed charges,121.91,73,,97.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.9,70,,93.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,19.19,,25.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.5,50,,66.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,137.78,
VANCOCIN 1900 MG/250 ML NS,25150248,CDM,636,RC,J3370,HCPCS,Outpatient,,,167,167,,,,,,Other,Not Separately Reimbursable,137.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,137.78,82.5,,110.224,percent of total billed charges,Pays at 82.5% of total Billed charges,121.91,73,,97.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.9,70,,93.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,19.19,,25.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.5,50,,66.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,137.78,
VANCOMYCIN INJ:1 GM,25150250,CDM,636,RC,J3370,HCPCS,Outpatient,,,77,77,,,,,,Other,Not Separately Reimbursable,63.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,63.53,82.5,,50.824,percent of total billed charges,Pays at 82.5% of total Billed charges,56.21,73,,44.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.9,70,,43.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,19.19,,11.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,50,,30.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,63.53,
VANCOCIN 1100 MG/250 ML NS,25150252,CDM,636,RC,J3370,HCPCS,Outpatient,,,167,167,,,,,,Other,Not Separately Reimbursable,137.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,137.78,82.5,,110.224,percent of total billed charges,Pays at 82.5% of total Billed charges,121.91,73,,97.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.9,70,,93.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,19.19,,25.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.5,50,,66.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,137.78,
VANCOCIN(VANCOMYCIN) 800 MG/250 ML,25150254,CDM,636,RC,J3370,HCPCS,Outpatient,,,167,167,,,,,,Other,Not Separately Reimbursable,137.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,137.78,82.5,,110.224,percent of total billed charges,Pays at 82.5% of total Billed charges,121.91,73,,97.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.9,70,,93.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,19.19,,25.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.5,50,,66.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,137.78,
VANCOMYCIN INJ:1 GM ADD-VANT,25150255,CDM,636,RC,J3370,HCPCS,Outpatient,,,73,73,,,,,,Other,Not Separately Reimbursable,60.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,60.23,82.5,,48.184,percent of total billed charges,Pays at 82.5% of total Billed charges,53.29,73,,42.632,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.1,70,,40.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.01,19.19,,11.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.5,50,,29.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.01,60.23,
VANCOCIN 2100 MG/250 ML NS,25150256,CDM,636,RC,J3370,HCPCS,Outpatient,,,167,167,,,,,,Other,Not Separately Reimbursable,137.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,137.78,82.5,,110.224,percent of total billed charges,Pays at 82.5% of total Billed charges,121.91,73,,97.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.9,70,,93.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,19.19,,25.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.5,50,,66.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,137.78,
VANCOCIN 2200 MG/250 ML NS,25150257,CDM,636,RC,J3370,HCPCS,Outpatient,,,167,167,,,,,,Other,Not Separately Reimbursable,137.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,137.78,82.5,,110.224,percent of total billed charges,Pays at 82.5% of total Billed charges,121.91,73,,97.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.9,70,,93.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,19.19,,25.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.5,50,,66.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,137.78,
VANCOCIN 2400 MG/250 ML NS,25150259,CDM,636,RC,J1580,HCPCS,Outpatient,,,167,167,,,,,,Other,Not Separately Reimbursable,137.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,137.78,82.5,,110.224,percent of total billed charges,Pays at 82.5% of total Billed charges,121.91,73,,97.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.9,70,,93.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,19.19,,25.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.5,50,,66.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,137.78,
GENTAMICIN INJ: 80MG,25150260,CDM,250,RC,J3370,HCPCS,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,9.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.08,82.5,,7.264,percent of total billed charges,Pays at 82.5% of total Billed charges,8.03,73,,6.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.7,70,,6.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,19.19,,1.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.5,50,,4.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,9.08,
VANCOCIN(VANCOMYCIN) 900 MG/250 ML,25150263,CDM,636,RC,J0713,HCPCS,Outpatient,,,167,167,,,,,,Other,Not Separately Reimbursable,137.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,137.78,82.5,,110.224,percent of total billed charges,Pays at 82.5% of total Billed charges,121.91,73,,97.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.9,70,,93.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,19.19,,25.64,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.5,50,,66.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.05,137.78,
FORTAZ(CEFTAZIDIME)INJ:500MG,25150310,CDM,250,RC,J0713,HCPCS,Outpatient,,,34,34,,,,,,Other,Not Separately Reimbursable,28.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.05,82.5,,22.44,percent of total billed charges,Pays at 82.5% of total Billed charges,24.82,73,,19.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,70,,19.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,19.19,,5.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17,50,,13.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,28.05,
CEFTAZIDIME(FORTAZ)INJ:1GM,25150315,CDM,250,RC,S0030,HCPCS,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,47.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.03,82.5,,37.624,percent of total billed charges,Pays at 82.5% of total Billed charges,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,47.03,
metroNIDAZOLE(FLAGYL)IVPB:500MG,25150340,CDM,250,RC,J0280,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
AMINOPHYLLINE INJ:250MG,25150400,CDM,636,RC,,,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,9.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.08,82.5,,7.264,percent of total billed charges,Pays at 82.5% of total Billed charges,8.03,73,,6.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.7,70,,6.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,19.19,,1.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.5,50,,4.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,9.08,
DEXTROSE 50% SYRINGE:25 GM,25150420,CDM,250,RC,,,Outpatient,,,68,68,,,,,,Other,Not Separately Reimbursable,56.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.1,82.5,,44.88,percent of total billed charges,Pays at 82.5% of total Billed charges,49.64,73,,39.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.6,70,,38.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,19.19,,10.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34,50,,27.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,56.1,
LIDOCAINE 2GM(4MG/ML)DRIP:500ML,25150510,CDM,250,RC,J0290,HCPCS,Outpatient,,,72,72,,,,,,Other,Not Separately Reimbursable,59.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,59.4,82.5,,47.52,percent of total billed charges,Pays at 82.5% of total Billed charges,52.56,73,,42.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.4,70,,40.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,19.19,,11.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36,50,,28.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,59.4,
AMPICILLIN INJ:500MG,25150530,CDM,636,RC,J0290,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,5.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,5.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,21.9,
AMPICILLIN INJ:2 GM,25150531,CDM,636,RC,J0694,HCPCS,Outpatient,,,86,86,,,,,,Other,Not Separately Reimbursable,5.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,5.86,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,62.78,73,,50.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.2,70,,48.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,19.19,,13.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43,50,,34.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.86,62.78,
CefOXitin (MEFOXIN) INJ: 1 GM,25150565,CDM,636,RC,J0694,HCPCS,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
CefOXitin (MEFOXIN) INJ: 2 GM,25150570,CDM,636,RC,J1364,HCPCS,Outpatient,,,123,123,,,,,,Other,Not Separately Reimbursable,101.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,101.48,82.5,,81.184,percent of total billed charges,Pays at 82.5% of total Billed charges,89.79,73,,71.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.1,70,,68.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.6,19.19,,18.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.5,50,,49.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.6,101.48,
ERYTHROMYCIN INJ:500MG,25150630,CDM,250,RC,S0021,HCPCS,Outpatient,,,37,37,,,,,,Other,Not Separately Reimbursable,30.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,30.53,82.5,,24.424,percent of total billed charges,Pays at 82.5% of total Billed charges,27.01,73,,21.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.9,70,,20.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,19.19,,5.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.5,50,,14.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,30.53,
DNU CEFOBID(CEFOPERAZONE)VIAL:1GM,25150670,CDM,250,RC,,,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
GLUCOPHAGE XR(METFORMIN)TAB:500 MG,25150680,CDM,250,RC,J0840,HCPCS,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
CROFAB(CROTALIDAE ANTIVENIN):2 ML VIAL,25150690,CDM,250,RC,J1940,HCPCS,Outpatient,,,9254,9254,,,,,,Other,Not Separately Reimbursable,7634.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,7634.55,82.5,,6107.64,percent of total billed charges,Pays at 82.5% of total Billed charges,6755.42,73,,5404.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6477.8,70,,5182.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1775.84,19.19,,1420.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4627,50,,3701.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1775.84,7634.55,
FUROSEMIDE(LASIX)INJ:20MG,25150750,CDM,250,RC,J1940,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,27.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.23,82.5,,21.784,percent of total billed charges,Pays at 82.5% of total Billed charges,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,27.23,
FUROSEMIDE(LASIX)INJ:40MG,25150755,CDM,250,RC,J1940,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,27.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.23,82.5,,21.784,percent of total billed charges,Pays at 82.5% of total Billed charges,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,27.23,
FUROSEMIDE(LASIX)INJ:100MG,25150760,CDM,250,RC,J1940,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
LASIX 100 MG/100 ML NS DRIP,25150761,CDM,250,RC,J1160,HCPCS,Outpatient,,,63,63,,,,,,Other,Not Separately Reimbursable,51.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,51.98,82.5,,41.584,percent of total billed charges,Pays at 82.5% of total Billed charges,45.99,73,,36.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.1,70,,35.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,19.19,,9.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,50,,25.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,51.98,
DIGOXIN(LANOXIN)INJ:0.5MG,25150800,CDM,250,RC,J0461,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
ATROPINE SYRINGE INJ:1MG/10ML,25150880,CDM,250,RC,J0461,HCPCS,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,71.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,71.78,82.5,,57.424,percent of total billed charges,Pays at 82.5% of total Billed charges,63.51,73,,50.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.9,70,,48.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,19.19,,13.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.5,50,,34.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,71.78,
ATROPINE PEDIATRIC 0.05MG/ML:0.25MG/5ML,25150885,CDM,250,RC,J1720,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
hydroCORTISONE(Solu-CORTEF)INJ:100MG,25150950,CDM,636,RC,J2920,HCPCS,Outpatient,,,103,103,,,,,,Other,Not Separately Reimbursable,84.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,84.98,82.5,,67.984,percent of total billed charges,Pays at 82.5% of total Billed charges,75.19,73,,60.152,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.1,70,,57.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.77,19.19,,15.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.5,50,,41.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.77,84.98,
methylPREDNISOLONE(SoluMEDROL)INJ:40MG,25150980,CDM,636,RC,J2930,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,12.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,12.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,55.48,
methylPREDNISOLONE(SoluMEDROL)INJ:125MG,25150990,CDM,636,RC,J2930,HCPCS,Outpatient,,,117,117,,,,,,Other,Not Separately Reimbursable,96.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,96.53,82.5,,77.224,percent of total billed charges,Pays at 82.5% of total Billed charges,85.41,73,,68.328,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.9,70,,65.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.45,19.19,,17.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.5,50,,46.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.45,96.53,
methylPREDNISOLONE(Solu-MEDROL)INJ: 1GM,25150992,CDM,636,RC,,,Outpatient,,,481,481,,,,,,Other,Not Separately Reimbursable,396.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,396.83,82.5,,317.464,percent of total billed charges,Pays at 82.5% of total Billed charges,351.13,73,,280.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,336.7,70,,269.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.3,19.19,,73.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,240.5,50,,192.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.3,396.83,
COMBIVIR(ZIDOVUDINE/LAMIVUDINE)TAB:300/1,25151090,CDM,250,RC,J1610,HCPCS,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
GLUCAGON(GLUCAGEN)INJ:1MG,25151120,CDM,636,RC,J2270,HCPCS,Outpatient,,,824,824,,,,,,Other,Not Separately Reimbursable,679.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,679.8,82.5,,543.84,percent of total billed charges,Pays at 82.5% of total Billed charges,601.52,73,,481.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,576.8,70,,461.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,158.13,19.19,,126.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,412,50,,329.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,158.13,679.8,
MORPHINE SULFATE INJ: 4MG,25151150,CDM,636,RC,J0595,HCPCS,Outpatient,,,23,23,,,,,,Other,Not Separately Reimbursable,18.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,82.5,,15.184,percent of total billed charges,Pays at 82.5% of total Billed charges,16.79,73,,13.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.1,70,,12.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,19.19,,3.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.5,50,,9.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,18.98,
BUTORPHANOL(STADOL)INJ:2MG,25151245,CDM,250,RC,J1410,HCPCS,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,47.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.03,82.5,,37.624,percent of total billed charges,Pays at 82.5% of total Billed charges,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,47.03,
PREMARIN (CONJ.ESTROGEN)INJ:25MG,25151250,CDM,636,RC,J2765,HCPCS,Outpatient,,,123,123,,,,,,Other,Not Separately Reimbursable,108.64,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,108.64,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,89.79,73,,71.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.1,70,,68.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.6,19.19,,18.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.5,50,,49.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.6,108.64,
METOCLOPRAMIDE(REGLAN) INJ: 10MG,25151260,CDM,636,RC,J1165,HCPCS,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,9.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.08,82.5,,7.264,percent of total billed charges,Pays at 82.5% of total Billed charges,8.03,73,,6.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.7,70,,6.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,19.19,,1.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.5,50,,4.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,9.08,
DILANTIN(PHENYTOIN)INJ: 100 MG,25151280,CDM,636,RC,J1165,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,26.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,26.4,82.5,,21.12,percent of total billed charges,Pays at 82.5% of total Billed charges,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,26.4,
DILANTIN(PHENYTOIN)INJ: 250 MG,25151285,CDM,636,RC,J1165,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DILANTIN 1000 MG IN 1000 ML NS,25151286,CDM,636,RC,,,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
DOXYCYCLINE(VIBRAMYCIN)INJ:100MG,25151320,CDM,250,RC,J1200,HCPCS,Outpatient,,,157,157,,,,,,Other,Not Separately Reimbursable,129.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,129.53,82.5,,103.624,percent of total billed charges,Pays at 82.5% of total Billed charges,114.61,73,,91.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.9,70,,87.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.13,19.19,,24.104,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.5,50,,62.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.13,129.53,
diphenhydrAMINE(BENADRYL)INJ:50MG,25151380,CDM,250,RC,,,Outpatient,,,37,37,,,,,,Other,Not Separately Reimbursable,30.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,30.53,82.5,,24.424,percent of total billed charges,Pays at 82.5% of total Billed charges,27.01,73,,21.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.9,70,,20.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,19.19,,5.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.5,50,,14.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,30.53,
LIDOCAINE 2% SYR: 50 MG CARDIAC,25151440,CDM,250,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
LIDOCAINE 2% SYRINGE 100MG:5ML,25151460,CDM,250,RC,,,Outpatient,,,21,21,,,,,,Other,Not Separately Reimbursable,17.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,17.33,82.5,,13.864,percent of total billed charges,Pays at 82.5% of total Billed charges,15.33,73,,12.264,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.7,70,,11.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,19.19,,3.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,50,,8.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,17.33,
BUMETANIDE(BUMEX)TAB:1MG,25151560,CDM,250,RC,,,Outpatient,,,27,27,,,,,,Other,Not Separately Reimbursable,22.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,22.28,82.5,,17.824,percent of total billed charges,Pays at 82.5% of total Billed charges,19.71,73,,15.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.9,70,,15.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,19.19,,4.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.5,50,,10.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,22.28,
ESMOLOL(BREVIBLOC)INJ:100MG,25151680,CDM,250,RC,J0696,HCPCS,Outpatient,,,234,234,,,,,,Other,Not Separately Reimbursable,193.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,193.05,82.5,,154.44,percent of total billed charges,Pays at 82.5% of total Billed charges,170.82,73,,136.656,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.8,70,,131.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.9,19.19,,35.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117,50,,93.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.9,193.05,
ROCEPHIN(CEFTRIAXONE)INJ:500 MG,25151700,CDM,636,RC,J0696,HCPCS,Outpatient,,,159,159,,,,,,Other,Not Separately Reimbursable,131.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,131.18,82.5,,104.944,percent of total billed charges,Pays at 82.5% of total Billed charges,116.07,73,,92.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.3,70,,89.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.51,19.19,,24.408,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.5,50,,63.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.51,131.18,
CEFTRIAXONE IM(ROCEPHIN)INJ:500MG,25151701,CDM,636,RC,J0696,HCPCS,Outpatient,,,107,107,,,,,,Other,Not Separately Reimbursable,88.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,88.28,82.5,,70.624,percent of total billed charges,Pays at 82.5% of total Billed charges,78.11,73,,62.488,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.9,70,,59.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.53,19.19,,16.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.5,50,,42.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.53,88.28,
ROCEPHIN 400 MG IN 50 ML NS,25151702,CDM,636,RC,J1250,HCPCS,Outpatient,,,107,107,,,,,,Other,Not Separately Reimbursable,88.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,88.28,82.5,,70.624,percent of total billed charges,Pays at 82.5% of total Billed charges,78.11,73,,62.488,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.9,70,,59.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.53,19.19,,16.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.5,50,,42.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.53,88.28,
DOBUTAMINE INJ:250 MG,25151720,CDM,250,RC,J2280,HCPCS,Outpatient,,,338,338,,,,,,Other,Not Separately Reimbursable,278.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,278.85,82.5,,223.08,percent of total billed charges,Pays at 82.5% of total Billed charges,246.74,73,,197.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,236.6,70,,189.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.86,19.19,,51.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,169,50,,135.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.86,278.85,
MOXIFLOXACIN(AVELOX)INJ:400MG/250ML,25151775,CDM,250,RC,J0744,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately Reimbursable,207.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,207.9,82.5,,166.32,percent of total billed charges,Pays at 82.5% of total Billed charges,183.96,73,,147.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.4,70,,141.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.36,19.19,,38.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126,50,,100.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.36,207.9,
CIPROFLOXACIN(CIPRO)200MG/100ML D5W,25151780,CDM,250,RC,J0744,HCPCS,Outpatient,,,117,117,,,,,,Other,Not Separately Reimbursable,96.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,96.53,82.5,,77.224,percent of total billed charges,Pays at 82.5% of total Billed charges,85.41,73,,68.328,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.9,70,,65.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.45,19.19,,17.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.5,50,,46.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.45,96.53,
CIPROFLOXACIN(CIPRO)400MG/200ML D5W,25151790,CDM,250,RC,J0610,HCPCS,Outpatient,,,197,197,,,,,,Other,Not Separately Reimbursable,162.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,162.53,82.5,,130.024,percent of total billed charges,Pays at 82.5% of total Billed charges,143.81,73,,115.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.9,70,,110.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,19.19,,30.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.5,50,,78.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,162.53,
CALCIUM GLUCONATE VIAL:10% 10ML,25151870,CDM,636,RC,J0610,HCPCS,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,4.06,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,4.06,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.06,80.3,
CALCIUM GLUCONATE 1 VIAL IN 100 ML,25151871,CDM,636,RC,J0610,HCPCS,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,4.06,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,4.06,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,10.95,
CALCIUM GLUCONATE 2 VIAL IN 100 ML NS,25151872,CDM,636,RC,J0610,HCPCS,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,4.06,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,4.06,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,10.95,
CALCIUM GLUCONATE 3 VIALS IN 250 ML NS,25151873,CDM,636,RC,J0610,HCPCS,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,4.06,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,4.06,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,10.95,
CALCIUM GLUCONATE 4 VIALS IN 250 ML NS,25151874,CDM,636,RC,J0171,HCPCS,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,4.06,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,4.06,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,10.95,
EPINEPHRINE SYRINGE:1MG/10ML,25151880,CDM,250,RC,J2310,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,43.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,43.73,82.5,,34.984,percent of total billed charges,Pays at 82.5% of total Billed charges,38.69,73,,30.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.1,70,,29.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,19.19,,8.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.5,50,,21.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,43.73,
NALOXONE(NARCAN)INJ:2MG/2ML,25151890,CDM,250,RC,J2310,HCPCS,Outpatient,,,278,278,,,,,,Other,Not Separately Reimbursable,229.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,229.35,82.5,,183.48,percent of total billed charges,Pays at 82.5% of total Billed charges,202.94,73,,162.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,194.6,70,,155.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.35,19.19,,42.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139,50,,111.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.35,229.35,
NALOXONE(NARCAN)INJ:0.4MG,25151895,CDM,250,RC,,,Outpatient,,,214,214,,,,,,Other,Not Separately Reimbursable,176.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,176.55,82.5,,141.24,percent of total billed charges,Pays at 82.5% of total Billed charges,156.22,73,,124.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.8,70,,119.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.07,19.19,,32.856,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107,50,,85.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.07,176.55,
METOPROLOL 1MG/ML INJ:5ML,25151930,CDM,250,RC,J0360,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,27.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.23,82.5,,21.784,percent of total billed charges,Pays at 82.5% of total Billed charges,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,27.23,
hydrALAZINE(APRESOLINE)INJ:20MG,25152030,CDM,636,RC,,,Outpatient,,,119,119,,,,,,Other,Not Separately Reimbursable,30.71,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,30.71,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,86.87,73,,69.496,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.3,70,,66.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.84,19.19,,18.272,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,50,,47.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.84,86.87,
DILTIAZEM(CARDIZEM)INJ:50MG/10ML,25152150,CDM,250,RC,,,Outpatient,,,37,37,,,,,,Other,Not Separately Reimbursable,30.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,30.53,82.5,,24.424,percent of total billed charges,Pays at 82.5% of total Billed charges,27.01,73,,21.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.9,70,,20.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,19.19,,5.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.5,50,,14.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,30.53,
DILTIAZEM(CARDIZEM)ADDV:100MG,25152155,CDM,250,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CARDIZEM(DILTIAZEM)100MG IN 100 ML NS,25152156,CDM,250,RC,,,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,75.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,75.9,82.5,,60.72,percent of total billed charges,Pays at 82.5% of total Billed charges,67.16,73,,53.728,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.4,70,,51.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,19.19,,14.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46,50,,36.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.65,75.9,
MVI-12(MULTIVITAMIN)INJ:1 AMP,25152210,CDM,250,RC,J2800,HCPCS,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
METHOCARBAMOL(ROBAXIN)INJ:1000MG,25152460,CDM,250,RC,J2800,HCPCS,Outpatient,,,428,428,,,,,,Other,Not Separately Reimbursable,353.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,353.1,82.5,,282.48,percent of total billed charges,Pays at 82.5% of total Billed charges,312.44,73,,249.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,299.6,70,,239.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.13,19.19,,65.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214,50,,171.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.13,353.1,
METHOcarbamol 1000 MG IN 100 ML NS,25152461,CDM,250,RC,J0153,HCPCS,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
ADENOSINE INJ 3MG/ML:2ML,25152640,CDM,636,RC,,,Outpatient,,,132,132,,,,,,Other,Not Separately Reimbursable,108.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,108.9,82.5,,87.12,percent of total billed charges,Pays at 82.5% of total Billed charges,96.36,73,,77.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.4,70,,73.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.33,19.19,,20.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66,50,,52.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.33,108.9,
SALINE FLUSH :3 ML SYRINGE,25153900,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
SALINE FLUSH :10 ML,25153901,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
SALINE FLUSH :10 ML #2,25153902,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
SALINE FLUSH :10 ML #3,25153903,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
SALINE FLUSH :10 ML #4,25153904,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
DEXTROSE 5% 50ML BAG,25158050,CDM,258,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
DEXTROSE 5% 100ML BAG,25158100,CDM,250,RC,,,Outpatient,,,77,77,,,,,,Other,Not Separately Reimbursable,63.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,63.53,82.5,,50.824,percent of total billed charges,Pays at 82.5% of total Billed charges,56.21,73,,44.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.9,70,,43.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,19.19,,11.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,50,,30.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,63.53,
DEXTROSE 5% 150ML BAG,25158150,CDM,250,RC,,,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
DEXTROSE 5% 250ML BAG,25158250,CDM,250,RC,,,Outpatient,,,83,83,,,,,,Other,Not Separately Reimbursable,68.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,68.48,82.5,,54.784,percent of total billed charges,Pays at 82.5% of total Billed charges,60.59,73,,48.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.1,70,,46.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.93,19.19,,12.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.5,50,,33.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.93,68.48,
NORMAL SALINE 50ML BAG,25159050,CDM,258,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
NORMAL SALINE ADD-VANT: 50ML,25159051,CDM,258,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
NORMAL SALINE 100ML BAG,25159100,CDM,258,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
NORMAL SALINE ADD-VANT: 100ML,25159101,CDM,258,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
NORMAL SALINE 150ML BAG,25159150,CDM,258,RC,J7050,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
NORMAL SALINE 250ML BAG,25159250,CDM,258,RC,J7050,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
NORMAL SALINE ADD-VANT:250ML,25159251,CDM,258,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
ETOMIDATE(AMIDATE)INJ 2MG/ML:20 ML,25170000,CDM,250,RC,J0171,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
EPINEPHRINE INJ:1MG,25170002,CDM,250,RC,J0171,HCPCS,Outpatient,,,180,180,,,,,,Other,Not Separately Reimbursable,148.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,148.5,82.5,,118.8,percent of total billed charges,Pays at 82.5% of total Billed charges,131.4,73,,105.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126,70,,100.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,19.19,,27.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90,50,,72,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,148.5,
EPINEPHRINE DRIP 8 MCG/ML 2 MG IN 250 ML,25170003,CDM,250,RC,,,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,15.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,15.68,82.5,,12.544,percent of total billed charges,Pays at 82.5% of total Billed charges,13.87,73,,11.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.3,70,,10.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,19.19,,2.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.5,50,,7.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,15.68,
OXYMETAZOLINE NASAL SPRAY 0.05%: 30ML,25170004,CDM,250,RC,J0330,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SUCCINYLCHOLINE(ANECTINE)INJ:200MG,25170010,CDM,250,RC,J3262,HCPCS,Outpatient,,,289,289,,,,,,Other,Not Separately Reimbursable,238.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,238.43,82.5,,190.744,percent of total billed charges,Pays at 82.5% of total Billed charges,210.97,73,,168.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,202.3,70,,161.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.46,19.19,,44.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.5,50,,115.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.46,238.43,
ACTEMRA 400 MG INJ,25170020,CDM,250,RC,,,Outpatient,,,6630,6630,,,,,,Other,Not Separately Reimbursable,5469.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5469.75,82.5,,4375.8,percent of total billed charges,Pays at 82.5% of total Billed charges,4839.9,73,,3871.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4641,70,,3712.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1272.3,19.19,,1017.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3315,50,,2652,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1272.3,5469.75,
ACTEMRA 800 MG IN 100 ML NS,25170021,CDM,250,RC,J1100,HCPCS,Outpatient,,,6630,6630,,,,,,Other,Not Separately Reimbursable,5469.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5469.75,82.5,,4375.8,percent of total billed charges,Pays at 82.5% of total Billed charges,4839.9,73,,3871.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4641,70,,3712.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1272.3,19.19,,1017.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3315,50,,2652,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1272.3,5469.75,
DECADRON(DEXAMETHASONE)INJ:1MG,25170060,CDM,250,RC,J1100,HCPCS,Outpatient,,,7,7,,,,,,Other,Not Separately Reimbursable,5.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5.78,82.5,,4.624,percent of total billed charges,Pays at 82.5% of total Billed charges,5.11,73,,4.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.9,70,,3.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,19.19,,1.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,50,,2.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,5.78,
DEXAMETHASONE(DECADRON)INJ:4MG,25170061,CDM,250,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
EPHEDRINE INJ 50MG/ML:1ML,25170070,CDM,250,RC,J3010,HCPCS,Outpatient,,,454,454,,,,,,Other,Not Separately Reimbursable,374.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,374.55,82.5,,299.64,percent of total billed charges,Pays at 82.5% of total Billed charges,331.42,73,,265.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,317.8,70,,254.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.12,19.19,,69.696,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,227,50,,181.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.12,374.55,
FENTANYL 50MCG/ML INJ: 2ML,25170080,CDM,636,RC,J1644,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
HEPARIN INJ:5000 UNITS,25170100,CDM,250,RC,J1790,HCPCS,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
DROPERIDOL(INAPSINE)INJ:5MG,25170110,CDM,250,RC,S0020,HCPCS,Outpatient,,,41,41,,,,,,Other,Not Separately Reimbursable,33.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33.83,82.5,,27.064,percent of total billed charges,Pays at 82.5% of total Billed charges,29.93,73,,23.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.7,70,,22.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,19.19,,6.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.5,50,,16.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,33.83,
BUPIVICAINE(MARCAINE)0.25%VIAL:10ML,25170160,CDM,250,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
PAVULON (PANCURONIUM) INJ : 10 MG,25170200,CDM,250,RC,,,Outpatient,,,23,23,,,,,,Other,Not Separately Reimbursable,18.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,82.5,,15.184,percent of total billed charges,Pays at 82.5% of total Billed charges,16.79,73,,13.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.1,70,,12.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,19.19,,3.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.5,50,,9.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,18.98,
PENTOTHAL(THIOPENTAL)INJ:500MG,25170210,CDM,250,RC,J2590,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
OXYTOCIN 10 UNIT INJ,25170220,CDM,250,RC,J2710,HCPCS,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,14.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.85,82.5,,11.88,percent of total billed charges,Pays at 82.5% of total Billed charges,13.14,73,,10.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,70,,10.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,19.19,,2.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9,50,,7.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,14.85,
NEOSTIGMINE 1MG/ML:10ML,25170230,CDM,250,RC,,,Outpatient,,,470,470,,,,,,Other,Not Separately Reimbursable,387.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,387.75,82.5,,310.2,percent of total billed charges,Pays at 82.5% of total Billed charges,343.1,73,,274.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329,70,,263.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,19.19,,72.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,235,50,,188,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,387.75,
PHYSOSTIGMINE INJ: 2 MG/2 ML,25170235,CDM,250,RC,J2720,HCPCS,Outpatient,,,86,86,,,,,,Other,Not Separately Reimbursable,70.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.95,82.5,,56.76,percent of total billed charges,Pays at 82.5% of total Billed charges,62.78,73,,50.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.2,70,,48.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,19.19,,13.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43,50,,34.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,70.95,
PROTAMINE INJ 10MG/ML:25ML,25170240,CDM,636,RC,,,Outpatient,,,245,245,,,,,,Other,Not Separately Reimbursable,12.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,12.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,178.85,73,,143.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,171.5,70,,137.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.02,19.19,,37.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.5,50,,98,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,178.85,
REGONAL (PYRIDOSTIGMINE) INJ : 5MG/ML,25170250,CDM,250,RC,,,Outpatient,,,128,128,,,,,,Other,Not Separately Reimbursable,105.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,105.6,82.5,,84.48,percent of total billed charges,Pays at 82.5% of total Billed charges,93.44,73,,74.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.6,70,,71.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,19.19,,19.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64,50,,51.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,105.6,
ROBINUL FOR OR (GLYCOPYRROLATE)INJ 20ML,25170260,CDM,250,RC,,,Outpatient,,,24,24,,,,,,Other,Not Separately Reimbursable,19.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,19.8,82.5,,15.84,percent of total billed charges,Pays at 82.5% of total Billed charges,17.52,73,,14.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.8,70,,13.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.61,19.19,,3.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12,50,,9.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.61,19.8,
SILVER NITRATE STICK APPLICATOR,25170270,CDM,250,RC,,,Outpatient,,,3,3,,,,,,Other,Not Separately Reimbursable,2.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2.48,82.5,,1.984,percent of total billed charges,Pays at 82.5% of total Billed charges,2.19,73,,1.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.1,70,,1.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,19.19,,0.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.5,50,,1.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.58,2.48,
TRACRIUM(ATRACURIUM)INJ:10MG/ML,25170280,CDM,250,RC,J2250,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
VERSED INJ 1ML:1MG/ML,25170300,CDM,250,RC,,,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,23.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.93,82.5,,19.144,percent of total billed charges,Pays at 82.5% of total Billed charges,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,23.93,
MIDAZOLAM(VERSED)SYRUP 2MG/ML:5ML,25170305,CDM,250,RC,J2250,HCPCS,Outpatient,,,49,49,,,,,,Other,Not Separately Reimbursable,40.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,40.43,82.5,,32.344,percent of total billed charges,Pays at 82.5% of total Billed charges,35.77,73,,28.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.3,70,,27.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,19.19,,7.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,50,,19.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,40.43,
MIDAZOLAM(VERSED)INJ 1MG/ML:2ML,25170310,CDM,250,RC,J2250,HCPCS,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
VERSED INJ:5 MG,25170315,CDM,250,RC,,,Outpatient,,,141,141,,,,,,Other,Not Separately Reimbursable,116.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,116.33,82.5,,93.064,percent of total billed charges,Pays at 82.5% of total Billed charges,102.93,73,,82.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.7,70,,78.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,19.19,,21.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.5,50,,56.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,116.33,
LIDOCAINE PF 1% INJ 30ML,25170321,CDM,250,RC,,,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,9.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.08,82.5,,7.264,percent of total billed charges,Pays at 82.5% of total Billed charges,8.03,73,,6.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.7,70,,6.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,19.19,,1.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.5,50,,4.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,9.08,
LIDOCAINE 1% W/EPI:20ML,25170330,CDM,250,RC,,,Outpatient,,,22,22,,,,,,Other,Not Separately Reimbursable,18.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.15,82.5,,14.52,percent of total billed charges,Pays at 82.5% of total Billed charges,16.06,73,,12.848,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.4,70,,12.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,19.19,,3.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11,50,,8.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,18.15,
LIDOCAINE 1% W/EPI PF 10 ML,25170331,CDM,250,RC,J1800,HCPCS,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,23.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.93,82.5,,19.144,percent of total billed charges,Pays at 82.5% of total Billed charges,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,23.93,
INDERAL(PROPRANOLOL)INJ:1MG,25170340,CDM,250,RC,J2370,HCPCS,Outpatient,,,16,16,,,,,,Other,Not Separately Reimbursable,13.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13.2,82.5,,10.56,percent of total billed charges,Pays at 82.5% of total Billed charges,11.68,73,,9.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.2,70,,8.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,19.19,,2.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8,50,,6.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,13.2,
PHENYLEPHRINE 1% INJ:10MG,25170380,CDM,250,RC,,,Outpatient,,,116,116,,,,,,Other,Not Separately Reimbursable,95.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,95.7,82.5,,76.56,percent of total billed charges,Pays at 82.5% of total Billed charges,84.68,73,,67.744,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.2,70,,64.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.26,19.19,,17.808,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58,50,,46.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.26,95.7,
TEARS ARTIFICIAL: 15ML,25170440,CDM,250,RC,,,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
LIDOCAINE 2% JELLY:5 ML TUBE,25170450,CDM,250,RC,,,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,25.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,25.58,82.5,,20.464,percent of total billed charges,Pays at 82.5% of total Billed charges,22.63,73,,18.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.7,70,,17.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,19.19,,4.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.5,50,,12.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,25.58,
LIDOCAINE 2% JEL: 5ML SYRINGE,25170451,CDM,250,RC,,,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,23.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.93,82.5,,19.144,percent of total billed charges,Pays at 82.5% of total Billed charges,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,23.93,
LIDOCAINE HCL 4% TOPICAL SOLN:50 ML,25170455,CDM,250,RC,J0330,HCPCS,Outpatient,,,83,83,,,,,,Other,Not Separately Reimbursable,68.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,68.48,82.5,,54.784,percent of total billed charges,Pays at 82.5% of total Billed charges,60.59,73,,48.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.1,70,,46.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.93,19.19,,12.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.5,50,,33.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.93,68.48,
ANECTINE (SUCCINYLCHOLINE) INJ:20MG/ML,25170480,CDM,250,RC,J1670,HCPCS,Outpatient,,,21,21,,,,,,Other,Not Separately Reimbursable,17.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,17.33,82.5,,13.864,percent of total billed charges,Pays at 82.5% of total Billed charges,15.33,73,,12.264,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.7,70,,11.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,19.19,,3.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,50,,8.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,17.33,
HYPER-TET (TETANUS IG) INJ : 250 UNIT,25180030,CDM,636,RC,J0558,HCPCS,Outpatient,,,416,416,,,,,,Other,Not Separately Reimbursable,343.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,343.2,82.5,,274.56,percent of total billed charges,Pays at 82.5% of total Billed charges,303.68,73,,242.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,291.2,70,,232.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.83,19.19,,63.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,208,50,,166.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.83,343.2,
BICILLIN CR INJ:1.2 MILLION UNITS,25180070,CDM,250,RC,,,Outpatient,,,1,1,,,,,,Other,Not Separately Reimbursable,0.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,0.83,82.5,,0.664,percent of total billed charges,Pays at 82.5% of total Billed charges,0.73,73,,0.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.7,70,,0.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.19,19.19,,0.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.5,50,,0.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.19,0.83,
NON FORMULARY MEDICATION,25180122,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
oxyCONTIN ER(oxyCODONE)TABS:10MG,25180124,CDM,250,RC,,,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,23.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.93,82.5,,19.144,percent of total billed charges,Pays at 82.5% of total Billed charges,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,23.93,
HYDROMORPHONE(DILAUDID)TAB:2MG,25180125,CDM,250,RC,J1170,HCPCS,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
HYDROmorphone(DILAUDID)INJ:2 MG/ML,25180126,CDM,250,RC,J1170,HCPCS,Outpatient,,,37,37,,,,,,Other,Not Separately Reimbursable,30.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,30.53,82.5,,24.424,percent of total billed charges,Pays at 82.5% of total Billed charges,27.01,73,,21.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.9,70,,20.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,19.19,,5.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.5,50,,14.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,30.53,
HYDROmorphone(DILAUDID)INJ:1 MG/ML,25180127,CDM,250,RC,J1170,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
DILAUDID (HYDROMORPHONE) INJ:50 MG/5 ML,25180128,CDM,250,RC,J1170,HCPCS,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
DILAUDID(HYDROMORPH) 100MG IN 100ML NS,25180129,CDM,250,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
oxyCONTIN ER(oxyCODONE)TABS:20MG,25180130,CDM,250,RC,J0670,HCPCS,Outpatient,,,49,49,,,,,,Other,Not Separately Reimbursable,40.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,40.43,82.5,,32.344,percent of total billed charges,Pays at 82.5% of total Billed charges,35.77,73,,28.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.3,70,,27.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,19.19,,7.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,50,,19.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,40.43,
MEPIVICAINE INJ 1.5%:30 ML,25199636,CDM,250,RC,,,Outpatient,,,61,61,,,,,,Other,Not Separately Reimbursable,50.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,50.33,82.5,,40.264,percent of total billed charges,Pays at 82.5% of total Billed charges,44.53,73,,35.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.7,70,,34.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,19.19,,9.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.5,50,,24.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,50.33,
CLONAZEPAM(KLONOPIN)TAB:0.5MG,25300177,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
KCL 20MEQ IN 1/2 NS 1000 ML,25300500,CDM,250,RC,J2543,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
PIPRACIL/TAZOBACTAM(ZOSYN)INJ:3.375GM,25300748,CDM,250,RC,,,Outpatient,,,107,107,,,,,,Other,Not Separately Reimbursable,88.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,88.28,82.5,,70.624,percent of total billed charges,Pays at 82.5% of total Billed charges,78.11,73,,62.488,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.9,70,,59.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.53,19.19,,16.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.5,50,,42.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.53,88.28,
NITROGLYCERIN DRIP: 50MG/250ML,25300758,CDM,250,RC,,,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,62.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,62.7,82.5,,50.16,percent of total billed charges,Pays at 82.5% of total Billed charges,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,62.7,
SENOKOT S TAB,25300759,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
KCL 20MEQ IN D5 1/2NS 1000 ML,25300792,CDM,250,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
KCL 20MEQ IN NS 1000ML,25300793,CDM,250,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
KCL 20 MEQ/100 ML INJECTION,25300800,CDM,250,RC,,,Outpatient,,,79,79,,,,,,Other,Not Separately Reimbursable,65.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,65.18,82.5,,52.144,percent of total billed charges,Pays at 82.5% of total Billed charges,57.67,73,,46.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.3,70,,44.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,19.19,,12.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.5,50,,31.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,65.18,
WARFARIN(COUMADIN)TAB:2 MG,25300802,CDM,250,RC,,,Outpatient,,,22,22,,,,,,Other,Not Separately Reimbursable,18.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.15,82.5,,14.52,percent of total billed charges,Pays at 82.5% of total Billed charges,16.06,73,,12.848,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.4,70,,12.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,19.19,,3.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11,50,,8.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,18.15,
LIDOCAINE 1% INJ:20ML,25300803,CDM,250,RC,,,Outpatient,,,39,39,,,,,,Other,Not Separately Reimbursable,32.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,32.18,82.5,,25.744,percent of total billed charges,Pays at 82.5% of total Billed charges,28.47,73,,22.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.3,70,,21.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,19.19,,5.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.5,50,,15.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,32.18,
MONTELUKAST(SINGULAIR)TAB:10 MG,25300807,CDM,250,RC,,,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
NITROGLYCERIN SR CAP:2.5 MG,25300811,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
KCL 40MEQ IN D5 1/2NS 1000 ML,25300834,CDM,250,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
KCL 20MEQ IN D5NS 1000ML,25300840,CDM,250,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
PIOGLITAZONE(ACTOS)TAB:15 MG,25300841,CDM,250,RC,,,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
KCL 40MEQ IN D5 NS 1000ML,25300845,CDM,250,RC,J0878,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
CUBICIN(DAPTOMYCIN)INJ: 500 MG,25300850,CDM,250,RC,J2020,HCPCS,Outpatient,,,560,560,,,,,,Other,Not Separately Reimbursable,462,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,462,82.5,,369.6,percent of total billed charges,Pays at 82.5% of total Billed charges,408.8,73,,327.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,392,70,,313.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.46,19.19,,85.968,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280,50,,224,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.46,462,
LINEZOLID (ZYVOX) INJ: 600MG/300ML IVPB,25310510,CDM,636,RC,,,Outpatient,,,619,619,,,,,,Other,Not Separately Reimbursable,510.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,510.68,82.5,,408.544,percent of total billed charges,Pays at 82.5% of total Billed charges,451.87,73,,361.496,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,433.3,70,,346.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,118.79,19.19,,95.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,309.5,50,,247.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,118.79,510.68,
KCL 40MEQ IN NS 1000 ML,25380045,CDM,250,RC,90662,HCPCS,Outpatient,,,93,93,,,,,,Other,Not Separately Reimbursable,76.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,76.73,82.5,,61.384,percent of total billed charges,Pays at 82.5% of total Billed charges,67.89,73,,54.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.1,70,,52.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.85,19.19,,14.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.5,50,,37.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.85,76.73,
FLU(HIGH DOSE>65 YO)VACCINE:0.5ML,25380049,CDM,636,RC,J2430,HCPCS,Outpatient,,,338,338,,,,,,Other,Not Separately Reimbursable,278.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,278.85,82.5,,223.08,percent of total billed charges,Pays at 82.5% of total Billed charges,246.74,73,,197.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,236.6,70,,189.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.86,19.19,,51.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,169,50,,135.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.86,278.85,
AREDIA(PAMIDRONATE) 30 MG INJ,25380050,CDM,636,RC,90715,HCPCS,Outpatient,,,288,288,,,,,,Other,Not Separately Reimbursable,237.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,237.6,82.5,,190.08,percent of total billed charges,Pays at 82.5% of total Billed charges,210.24,73,,168.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,201.6,70,,161.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.27,19.19,,44.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144,50,,115.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.27,237.6,
"Diphtheria, tetanus acellular, and pertussis vaccine for adults",25380051,CDM,250,RC,,,Outpatient,,,414,414,,,,,,Other,Not Separately Reimbursable,341.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,341.55,82.5,,273.24,percent of total billed charges,Pays at 82.5% of total Billed charges,302.22,73,,241.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,289.8,70,,231.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.45,19.19,,63.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,207,50,,165.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.45,341.55,
CARVEDILOL (COREG) TAB: 25MG,25380052,CDM,250,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
LevETIRAcetam(KEPPRA)TAB:500MG,25380054,CDM,250,RC,,,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,26.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,26.4,82.5,,21.12,percent of total billed charges,Pays at 82.5% of total Billed charges,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,26.4,
LEVOTHYROXINE (SYNTHROID)TAB:0.1MG,25380067,CDM,250,RC,J0282,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
AMIODARONE(NEXTERONE)RTU:150MG/100ML,25380068,CDM,636,RC,J0282,HCPCS,Outpatient,,,400,400,,,,,,Other,Not Separately Reimbursable,330,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,330,82.5,,264,percent of total billed charges,Pays at 82.5% of total Billed charges,292,73,,233.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,280,70,,224,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.76,19.19,,61.408,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,200,50,,160,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.76,330,
AMIODARONE(NEXTERONE)RTU:360MG/200ML,25380069,CDM,636,RC,J3430,HCPCS,Outpatient,,,2769,2769,,,,,,Other,Not Separately Reimbursable,2284.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2284.43,82.5,,1827.544,percent of total billed charges,Pays at 82.5% of total Billed charges,2021.37,73,,1617.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1938.3,70,,1550.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,531.37,19.19,,425.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1384.5,50,,1107.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,531.37,2284.43,
MEPHYTON(PHYTONADIONE)INJ USED PO,25380074,CDM,636,RC,,,Outpatient,,,264,264,,,,,,Other,Not Separately Reimbursable,217.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,217.8,82.5,,174.24,percent of total billed charges,Pays at 82.5% of total Billed charges,192.72,73,,154.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,184.8,70,,147.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.66,19.19,,40.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132,50,,105.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.66,217.8,
DETEMIR(LEVEMIR)INSULIN,25380125,CDM,250,RC,,,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,7.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,7.43,82.5,,5.944,percent of total billed charges,Pays at 82.5% of total Billed charges,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,7.43,
SODIUM BICARBONATE TAB: 650MG,25380126,CDM,250,RC,J7325,HCPCS,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
SYNVISC-ONE PFS 6ML INJECTION,25380127,CDM,250,RC,J7325,HCPCS,Outpatient,,,2595,2595,,,,,,Other,Not Separately Reimbursable,2140.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2140.88,82.5,,1712.704,percent of total billed charges,Pays at 82.5% of total Billed charges,1894.35,73,,1515.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1816.5,70,,1453.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,497.98,19.19,,398.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1297.5,50,,1038,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,497.98,2140.88,
SYNVISC PFS 2ML INJ 3 SYRINGES,25380128,CDM,250,RC,,,Outpatient,,,2595,2595,,,,,,Other,Not Separately Reimbursable,2140.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2140.88,82.5,,1712.704,percent of total billed charges,Pays at 82.5% of total Billed charges,1894.35,73,,1515.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1816.5,70,,1453.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,497.98,19.19,,398.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1297.5,50,,1038,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,497.98,2140.88,
IMIPRAMINE(TOFRANIL)TAB:50MG,25380135,CDM,250,RC,,,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,14.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.85,82.5,,11.88,percent of total billed charges,Pays at 82.5% of total Billed charges,13.14,73,,10.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,70,,10.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,19.19,,2.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9,50,,7.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,14.85,
LAMOTRIGINE(LAMICTAL)TAB:100MG,25380151,CDM,250,RC,P9047,HCPCS,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
ALBUMIN 25% 100 ML: 25 GM,25380162,CDM,636,RC,J2916,HCPCS,Outpatient,,,180,180,,,,,,Other,Not Separately Reimbursable,148.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,148.5,82.5,,118.8,percent of total billed charges,Pays at 82.5% of total Billed charges,131.4,73,,105.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126,70,,100.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,19.19,,27.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90,50,,72,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,148.5,
FERRIC GLUC (IRON SUCROSE)INJ: 62.5MG,25380196,CDM,636,RC,J0897,HCPCS,Outpatient,,,268,268,,,,,,Other,Not Separately Reimbursable,221.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,221.1,82.5,,176.88,percent of total billed charges,Pays at 82.5% of total Billed charges,195.64,73,,156.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,187.6,70,,150.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.43,19.19,,41.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,134,50,,107.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.43,221.1,
PROLIA(DENOSUMAB)INJ:60MG,25380199,CDM,636,RC,J2543,HCPCS,Outpatient,,,5852,5852,,,,,,Other,Not Separately Reimbursable,4827.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4827.9,82.5,,3862.32,percent of total billed charges,Pays at 82.5% of total Billed charges,4271.96,73,,3417.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4096.4,70,,3277.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1123,19.19,,898.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2926,50,,2340.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1123,4827.9,
PIPRACIL/TAZOBACTAM(ZOSYN)INJ:2.25GM,25380200,CDM,250,RC,J2543,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
PIPRACIL/TAZOBACTAM(ZOSYN)INJ:4.5GM,25380201,CDM,250,RC,J3370,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
VANCOMYCIN ORAL SOLUTION,25380206,CDM,636,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
metFORMIN ER(GLUCOPHAGE ER)TAB:500MG,25380219,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
MINERAL OIL (TOPICAL) STERILE: 25ML,25380256,CDM,250,RC,,,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,20.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,20.63,82.5,,16.504,percent of total billed charges,Pays at 82.5% of total Billed charges,18.25,73,,14.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,70,,14,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,19.19,,3.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,50,,10,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,20.63,
SUMATRIPTAN(IMITREX)TAB:50MG,25380257,CDM,250,RC,,,Outpatient,,,176,176,,,,,,Other,Not Separately Reimbursable,145.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,145.2,82.5,,116.16,percent of total billed charges,Pays at 82.5% of total Billed charges,128.48,73,,102.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,123.2,70,,98.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.77,19.19,,27.016,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88,50,,70.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.77,145.2,
WARFARIN(COUMADIN)TAB:3MG,25380268,CDM,250,RC,,,Outpatient,,,23,23,,,,,,Other,Not Separately Reimbursable,18.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,82.5,,15.184,percent of total billed charges,Pays at 82.5% of total Billed charges,16.79,73,,13.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.1,70,,12.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,19.19,,3.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.5,50,,9.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,18.98,
HYDROcodone/HOMATROPINE 5MG-1.5MG:5ML,25380277,CDM,250,RC,J0456,HCPCS,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,31.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,31.35,82.5,,25.08,percent of total billed charges,Pays at 82.5% of total Billed charges,27.74,73,,22.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.6,70,,21.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,19.19,,5.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,50,,15.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,31.35,
AZITHROMYCIN(ZITHROMAX)INJ:500MG,25380284,CDM,250,RC,J3410,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
hydrOXYzine(VISTARIL)INJ:25MG,25380285,CDM,250,RC,,,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,31.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,31.35,82.5,,25.08,percent of total billed charges,Pays at 82.5% of total Billed charges,27.74,73,,22.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.6,70,,21.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,19.19,,5.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,50,,15.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,31.35,
hydroCORTISONE(CORTEF)TAB:20MG,25380286,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
hydroCORTISONE(CORTEF)TAB:10MG,25380289,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
TRICHLOROACTIC ACID(TRI-CHLOR)SOLN: 15ML,25380350,CDM,250,RC,,,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
PEG 3350(MIRALAX)POWDER:238GM,25380394,CDM,250,RC,,,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,72.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,72.6,82.5,,58.08,percent of total billed charges,Pays at 82.5% of total Billed charges,64.24,73,,51.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,70,,49.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,19.19,,13.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44,50,,35.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,72.6,
NF-RID SHAMPOO,25380409,CDM,250,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
rOPINIRole(REQUIP)TAB:1MG,25380421,CDM,250,RC,S0077,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CLINDAMYCIN 300MG INJ:2ML,25380432,CDM,250,RC,,,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
LEVOFLOXACIN(LEVAQUIN)TAB:750MG,25380436,CDM,250,RC,,,Outpatient,,,173,173,,,,,,Other,Not Separately Reimbursable,142.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,142.73,82.5,,114.184,percent of total billed charges,Pays at 82.5% of total Billed charges,126.29,73,,101.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121.1,70,,96.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.2,19.19,,26.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.5,50,,69.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.2,142.73,
PROPOFOL(DIPRIVAN)INJ: 50ML,25380455,CDM,250,RC,,,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,62.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,62.7,82.5,,50.16,percent of total billed charges,Pays at 82.5% of total Billed charges,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,62.7,
NF-SCOPOLAMINE TD PATCH ER 0.33MG/24HR,25380469,CDM,250,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
SPIRIVA INH/NEB CAP: 18MCG,25380470,CDM,250,RC,J7608,HCPCS,Outpatient,,,220,220,,,,,,Other,Not Separately Reimbursable,181.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,181.5,82.5,,145.2,percent of total billed charges,Pays at 82.5% of total Billed charges,160.6,73,,128.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154,70,,123.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,19.19,,33.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110,50,,88,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,181.5,
ACETYLCYSTEINE(MUCOMYST)SOL 20%:30ML,25380478,CDM,250,RC,,,Outpatient,,,96,96,,,,,,Other,Not Separately Reimbursable,79.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,79.2,82.5,,63.36,percent of total billed charges,Pays at 82.5% of total Billed charges,70.08,73,,56.064,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.2,70,,53.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,19.19,,14.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48,50,,38.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,79.2,
"ESTROGEN,CONJ(PREMARIN)CR:30GM",25380481,CDM,250,RC,,,Outpatient,,,829,829,,,,,,Other,Not Separately Reimbursable,683.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,683.93,82.5,,547.144,percent of total billed charges,Pays at 82.5% of total Billed charges,605.17,73,,484.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,580.3,70,,464.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,159.09,19.19,,127.272,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,414.5,50,,331.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,159.09,683.93,
KCL 10 MEQ/100 ML INJECTION,25380521,CDM,250,RC,J3260,HCPCS,Outpatient,,,69,69,,,,,,Other,Not Separately Reimbursable,56.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.93,82.5,,45.544,percent of total billed charges,Pays at 82.5% of total Billed charges,50.37,73,,40.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.3,70,,38.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.24,19.19,,10.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,50,,27.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.24,56.93,
TOBRAMYCIN 80 MG IN 100 ML NS,25380557,CDM,250,RC,,,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
MetroNIDAZOLE(FLAGYL)TAB:500MG,25380578,CDM,250,RC,J1756,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
VENOFER(IRON SUCROSE)100MG IN 100ML NS,25380579,CDM,636,RC,J0585,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
BOTOX VIAL: 50 UNIT,25380582,CDM,250,RC,,,Outpatient,,,1589,1589,,,,,,Other,Not Separately Reimbursable,1310.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1310.93,82.5,,1048.744,percent of total billed charges,Pays at 82.5% of total Billed charges,1159.97,73,,927.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1112.3,70,,889.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,304.93,19.19,,243.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,794.5,50,,635.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,304.93,1310.93,
NEOMYCIN TAB:500MG,25380602,CDM,250,RC,J3010,HCPCS,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
FENTANYL 50MCG/ML INJ:5ML,25380604,CDM,636,RC,,,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,23.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.1,82.5,,18.48,percent of total billed charges,Pays at 82.5% of total Billed charges,20.44,73,,16.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.6,70,,15.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,19.19,,4.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,50,,11.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,23.1,
LIDOCAINE 4% TOPICAL SYRINGE:4ML,25380645,CDM,250,RC,,,Outpatient,,,168,168,,,,,,Other,Not Separately Reimbursable,138.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,138.6,82.5,,110.88,percent of total billed charges,Pays at 82.5% of total Billed charges,122.64,73,,98.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.6,70,,94.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.24,19.19,,25.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,50,,67.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.24,138.6,
BACITRACIN OINT PKT:0.9GM,25380662,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
HYDROCORTISONE CR 1% PKG:1.5GM,25380733,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
RIVAROXABAN(XARELTO)TAB:15MG,25380750,CDM,250,RC,,,Outpatient,,,107,107,,,,,,Other,Not Separately Reimbursable,88.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,88.28,82.5,,70.624,percent of total billed charges,Pays at 82.5% of total Billed charges,78.11,73,,62.488,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.9,70,,59.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.53,19.19,,16.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.5,50,,42.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.53,88.28,
RIVAROXABAN(XARELTO)TAB:10MG,25380751,CDM,250,RC,,,Outpatient,,,107,107,,,,,,Other,Not Separately Reimbursable,88.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,88.28,82.5,,70.624,percent of total billed charges,Pays at 82.5% of total Billed charges,78.11,73,,62.488,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.9,70,,59.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.53,19.19,,16.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.5,50,,42.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.53,88.28,
SITAGLIPTIN(JANUVIA)TAB:100MG,25380764,CDM,250,RC,,,Outpatient,,,145,145,,,,,,Other,Not Separately Reimbursable,119.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,119.63,82.5,,95.704,percent of total billed charges,Pays at 82.5% of total Billed charges,105.85,73,,84.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.5,70,,81.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.83,19.19,,22.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.5,50,,58,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.83,119.63,
EPOGEN 2000U/ML INJECTION SOLUTION,25380772,CDM,250,RC,,,Outpatient,,,1110,1110,,,,,,Other,Not Separately Reimbursable,915.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,915.75,82.5,,732.6,percent of total billed charges,Pays at 82.5% of total Billed charges,810.3,73,,648.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,777,70,,621.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,213.01,19.19,,170.408,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,555,50,,444,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,213.01,915.75,
FENTANYL(DURAGESIC)PATCH:75MCG/HR,25380795,CDM,250,RC,J1644,HCPCS,Outpatient,,,242,242,,,,,,Other,Not Separately Reimbursable,199.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,199.65,82.5,,159.72,percent of total billed charges,Pays at 82.5% of total Billed charges,176.66,73,,141.328,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,169.4,70,,135.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.44,19.19,,37.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121,50,,96.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.44,199.65,
"HEPARIN INJ:10,000 UNIT/ML",25380796,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
CLARITHROMYCIN(BIAXIN)TAB:500MG,25380806,CDM,250,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
AMOXICILLIN CAP:500MG,25380807,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ZIPRASIDONE(GEODON)CAP:20MG,25380815,CDM,250,RC,90656,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
Flu shot-high dose for 2019-2020 flu season given by injection,25380831,CDM,636,RC,,,Outpatient,,,835,835,,,,,,Other,Not Separately Reimbursable,688.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,688.88,82.5,,551.104,percent of total billed charges,Pays at 82.5% of total Billed charges,609.55,73,,487.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,584.5,70,,467.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,160.24,19.19,,128.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,417.5,50,,334,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,160.24,688.88,
CETIRIZINE(ZYRTEC)TAB:10MG,25380833,CDM,250,RC,,,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,20.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,20.63,82.5,,16.504,percent of total billed charges,Pays at 82.5% of total Billed charges,18.25,73,,14.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,70,,14,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,19.19,,3.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,50,,10,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,20.63,
MEMANTINE(NAMENDA)TAB:10MG,25380856,CDM,250,RC,,,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,47.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.03,82.5,,37.624,percent of total billed charges,Pays at 82.5% of total Billed charges,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,47.03,
MYCOPHENOLATE(CELLCEPT)CAP:250MG,25380903,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
NEBIVOLOL(BYSTOLIC)TAB:10MG,25380966,CDM,250,RC,J1165,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
FOSPHENYTOIN(CEREBYX)INJ 100MG PE:2ML,25380986,CDM,636,RC,J1100,HCPCS,Outpatient,,,359,359,,,,,,Other,Not Separately Reimbursable,296.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,296.18,82.5,,236.944,percent of total billed charges,Pays at 82.5% of total Billed charges,262.07,73,,209.656,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,251.3,70,,201.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.89,19.19,,55.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.5,50,,143.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.89,296.18,
DEXAMETHASONE(DECADRON)INJ 10MG:1ML,25380996,CDM,250,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
CALCITRIOL CAP: 0.25MCG,25381020,CDM,250,RC,J3475,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
MAGNESIUM SULF 1GM / 100ML NS,25381042,CDM,636,RC,J3475,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
MAGNESIUM SULFATE 50% 5GM:10ML,25381043,CDM,636,RC,,,Outpatient,,,27,27,,,,,,Other,Not Separately Reimbursable,22.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,22.28,82.5,,17.824,percent of total billed charges,Pays at 82.5% of total Billed charges,19.71,73,,15.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.9,70,,15.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,19.19,,4.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.5,50,,10.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,22.28,
D5W W/1 AMP SODIUM BICARB 8.4% 1LITER,25381048,CDM,258,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
MELATONIN TAB:3MG,25381074,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
NF-HUMALOG 100U/ML:10ML,25381108,CDM,250,RC,,,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
MINOCYCLINE CAP:100MG,25381141,CDM,250,RC,,,Outpatient,,,17,17,,,,,,Other,Not Separately Reimbursable,14.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.03,82.5,,11.224,percent of total billed charges,Pays at 82.5% of total Billed charges,12.41,73,,9.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.9,70,,9.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.26,19.19,,2.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.5,50,,6.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.26,14.03,
HYDROCODONE 7.5MG/APAP 325MG TAB,25381157,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
THIAMINE(VITAMIN B-1)TAB:100MG,25381159,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
HYDROCODONE/APAP SOLN 5/217:10ML,25381211,CDM,250,RC,,,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
SODIUM BICARBONATE 4.2%:5ML,25381275,CDM,250,RC,,,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,25.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,25.58,82.5,,20.464,percent of total billed charges,Pays at 82.5% of total Billed charges,22.63,73,,18.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.7,70,,17.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,19.19,,4.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.5,50,,12.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,25.58,
KCL 20MEQ IN D5W 1000ML,25381286,CDM,258,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
ALBUTEROL HFA INH (OR CHARGE),25381287,CDM,250,RC,,,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
LINEZOLID(ZYVOX)TAB:600MG,25381335,CDM,250,RC,J1815,HCPCS,Outpatient,,,615,615,,,,,,Other,Not Separately Reimbursable,507.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,507.38,82.5,,405.904,percent of total billed charges,Pays at 82.5% of total Billed charges,448.95,73,,359.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,430.5,70,,344.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,118.02,19.19,,94.416,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,307.5,50,,246,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,118.02,507.38,
ASPART INSULIN/NOVOLOG,25381340,CDM,250,RC,J3370,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
VANCOMYCIN INJ:750 MG,25381438,CDM,636,RC,,,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
BUTALB/ACET/CAFF(FIORICET)50/325/40 TAB,25381448,CDM,250,RC,J0834,HCPCS,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,20.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,20.63,82.5,,16.504,percent of total billed charges,Pays at 82.5% of total Billed charges,18.25,73,,14.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,70,,14,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,19.19,,3.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,50,,10,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,20.63,
COSYNTROPIN(CORTROSYN)INJ:0.25MG,25381482,CDM,636,RC,90736,HCPCS,Outpatient,,,512,512,,,,,,Other,Not Separately Reimbursable,422.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,422.4,82.5,,337.92,percent of total billed charges,Pays at 82.5% of total Billed charges,373.76,73,,299.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,358.4,70,,286.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.25,19.19,,78.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,256,50,,204.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.25,422.4,
Shingles vaccine,25381497,CDM,636,RC,J0690,HCPCS,Outpatient,,,836,836,,,,,,Other,Not Separately Reimbursable,689.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,689.7,82.5,,551.76,percent of total billed charges,Pays at 82.5% of total Billed charges,610.28,73,,488.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,585.2,70,,468.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,160.43,19.19,,128.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,418,50,,334.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,160.43,689.7,
CEFAZOLIN(ANCEF)2GM/50ML,25381521,CDM,636,RC,,,Outpatient,,,79,79,,,,,,Other,Not Separately Reimbursable,65.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,65.18,82.5,,52.144,percent of total billed charges,Pays at 82.5% of total Billed charges,57.67,73,,46.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.3,70,,44.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,19.19,,12.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.5,50,,31.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.16,65.18,
apiXaban(ELIQUIS)TAB:5MG,25381553,CDM,250,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
ALENDRONATE TAB:70MG,25381577,CDM,250,RC,,,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
LIDOCAINE 2% INJ:2ML,25381611,CDM,250,RC,,,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
ONDANSETRON ODT:4MG,25381617,CDM,250,RC,J0692,HCPCS,Outpatient,,,157,157,,,,,,Other,Not Separately Reimbursable,129.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,129.53,82.5,,103.624,percent of total billed charges,Pays at 82.5% of total Billed charges,114.61,73,,91.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.9,70,,87.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.13,19.19,,24.104,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.5,50,,62.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.13,129.53,
CEFEPIME(MAXIPIME)INJ:2GM,25381653,CDM,250,RC,J1335,HCPCS,Outpatient,,,96,96,,,,,,Other,Not Separately Reimbursable,79.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,79.2,82.5,,63.36,percent of total billed charges,Pays at 82.5% of total Billed charges,70.08,73,,56.064,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.2,70,,53.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,19.19,,14.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48,50,,38.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,79.2,
ERTAPENEM(INVANZ)INJ:1GM,25381716,CDM,250,RC,,,Outpatient,,,672,672,,,,,,Other,Not Separately Reimbursable,554.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,554.4,82.5,,443.52,percent of total billed charges,Pays at 82.5% of total Billed charges,490.56,73,,392.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,470.4,70,,376.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.96,19.19,,103.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,336,50,,268.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.96,554.4,
PRIMIDONE TAB:50MG,25381741,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
REFRESH CELLUVISC EYE GEL:0.4ML,25381744,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
DRONABINOL CAP:2.5MG,25381777,CDM,250,RC,,,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
GENTAMICIN 0.1% CREAM:15GM,25381780,CDM,250,RC,,,Outpatient,,,231,231,,,,,,Other,Not Separately Reimbursable,190.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,190.58,82.5,,152.464,percent of total billed charges,Pays at 82.5% of total Billed charges,168.63,73,,134.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.7,70,,129.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.33,19.19,,35.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.5,50,,92.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.33,190.58,
CLINIMIX E 5% W/DEXTROSE 15%1000 ML,25381800,CDM,250,RC,,,Outpatient,,,341,341,,,,,,Other,Not Separately Reimbursable,281.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,281.33,82.5,,225.064,percent of total billed charges,Pays at 82.5% of total Billed charges,248.93,73,,199.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,238.7,70,,190.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.44,19.19,,52.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.5,50,,136.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.44,281.33,
VERAPAMIL TAB:80MG,25381837,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
BUSPIRONE(BUSPAR)TAB:5MG,25381838,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
ERYTHROMYCIN OPHTH OINT 0.5%:3.5GM,25381865,CDM,250,RC,,,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,123.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,123.75,82.5,,99,percent of total billed charges,Pays at 82.5% of total Billed charges,109.5,73,,87.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,70,,84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,19.19,,23.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75,50,,60,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,123.75,
COLESEVELAM TAB: 625MG,25381868,CDM,250,RC,,,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
CLINIMIX E 5% W/DEXTROSE 20%1000 ML,25381877,CDM,250,RC,J1165,HCPCS,Outpatient,,,256,256,,,,,,Other,Not Separately Reimbursable,211.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,211.2,82.5,,168.96,percent of total billed charges,Pays at 82.5% of total Billed charges,186.88,73,,149.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.2,70,,143.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.13,19.19,,39.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128,50,,102.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.13,211.2,
leveTIRACETAM(KEPPRA)INJ:500MG,25381892,CDM,636,RC,,,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
RANITIDINE(ZANTAC)INJ:50MG,25381896,CDM,250,RC,,,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,25.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,25.58,82.5,,20.464,percent of total billed charges,Pays at 82.5% of total Billed charges,22.63,73,,18.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.7,70,,17.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,19.19,,4.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.5,50,,12.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,25.58,
ZOLPIDEM TABLET :10MG,25381901,CDM,250,RC,,,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,38.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,38.78,82.5,,31.024,percent of total billed charges,Pays at 82.5% of total Billed charges,34.31,73,,27.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.9,70,,26.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,19.19,,7.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.5,50,,18.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,38.78,
OFLOXACIN(OCUFLOX)OTIC SOLN:0.3%:5ML,25381921,CDM,250,RC,,,Outpatient,,,144,144,,,,,,Other,Not Separately Reimbursable,118.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,118.8,82.5,,95.04,percent of total billed charges,Pays at 82.5% of total Billed charges,105.12,73,,84.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.8,70,,80.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.63,19.19,,22.104,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72,50,,57.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.63,118.8,
MAGNESIUM SULFATE 2GM/50 ML INJECTION,25381927,CDM,250,RC,,,Outpatient,,,193,193,,,,,,Other,Not Separately Reimbursable,159.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,159.23,82.5,,127.384,percent of total billed charges,Pays at 82.5% of total Billed charges,140.89,73,,112.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,135.1,70,,108.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.04,19.19,,29.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.5,50,,77.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.04,159.23,
GLIMEPIRIDE(AMARYL)TAB:2MG,25381942,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
PERMETHRIN(LICE TX)CR 1%:60GM,25381943,CDM,250,RC,,,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,20.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,20.63,82.5,,16.504,percent of total billed charges,Pays at 82.5% of total Billed charges,18.25,73,,14.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,70,,14,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,19.19,,3.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,50,,10,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,20.63,
PERMETHRIN(ELIMITE)CR 5%:60GM,25381951,CDM,250,RC,90702,HCPCS,Outpatient,,,476,476,,,,,,Other,Not Separately Reimbursable,392.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,392.7,82.5,,314.16,percent of total billed charges,Pays at 82.5% of total Billed charges,347.48,73,,277.984,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,333.2,70,,266.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.34,19.19,,73.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,238,50,,190.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.34,392.7,
DIPHTHERIA TETANUS CHILD(DT<7):0.5ML,25381969,CDM,250,RC,J1040,HCPCS,Outpatient,,,479,479,,,,,,Other,Not Separately Reimbursable,395.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,395.18,82.5,,316.144,percent of total billed charges,Pays at 82.5% of total Billed charges,349.67,73,,279.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,335.3,70,,268.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.92,19.19,,73.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,239.5,50,,191.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.92,395.18,
methylPREDNISOLONE(DepoMEDROL)INJ:80MG,25381973,CDM,250,RC,,,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
LIDOCAINE PATCH ER 5%,25382009,CDM,250,RC,J1815,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,165,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,165,82.5,,132,percent of total billed charges,Pays at 82.5% of total Billed charges,146,73,,116.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,70,,112,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,19.19,,30.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100,50,,80,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,165,
HUMULIN/NOVOLIN R INSULIN SLIDING SCALE,25382084,CDM,250,RC,J0878,HCPCS,Outpatient,,,1,1,,,,,,Other,Not Separately Reimbursable,0.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,0.83,82.5,,0.664,percent of total billed charges,Pays at 82.5% of total Billed charges,0.73,73,,0.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.7,70,,0.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.19,19.19,,0.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.5,50,,0.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.19,0.83,
DAPTOMYCIN(CUBICIN)INJ:500 MG,25382086,CDM,636,RC,,,Outpatient,,,1703,1703,,,,,,Other,Not Separately Reimbursable,1404.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1404.98,82.5,,1123.984,percent of total billed charges,Pays at 82.5% of total Billed charges,1243.19,73,,994.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1192.1,70,,953.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,326.81,19.19,,261.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,851.5,50,,681.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,326.81,1404.98,
SODIUM BICARB 1 AMP IN NS 1000ML,25382127,CDM,250,RC,,,Outpatient,,,72,72,,,,,,Other,Not Separately Reimbursable,59.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,59.4,82.5,,47.52,percent of total billed charges,Pays at 82.5% of total Billed charges,52.56,73,,42.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.4,70,,40.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,19.19,,11.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36,50,,28.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,59.4,
LEVOTHYROXINE (SYNTHROID)TAB:0.088MG,25382142,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DAKIN SOLN QUARTER STRENGTH:473ML,25382196,CDM,250,RC,,,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,31.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,31.35,82.5,,25.08,percent of total billed charges,Pays at 82.5% of total Billed charges,27.74,73,,22.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.6,70,,21.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,19.19,,5.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,50,,15.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,31.35,
DAKIN SOLN FULL STRENGTH:473ML,25382197,CDM,250,RC,,,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,31.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,31.35,82.5,,25.08,percent of total billed charges,Pays at 82.5% of total Billed charges,27.74,73,,22.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.6,70,,21.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,19.19,,5.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19,50,,15.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.29,31.35,
OXCARBAZEPINE(TRILEPTAL)TAB:300MG,25382236,CDM,250,RC,,,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,23.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.1,82.5,,18.48,percent of total billed charges,Pays at 82.5% of total Billed charges,20.44,73,,16.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.6,70,,15.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,19.19,,4.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,50,,11.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,23.1,
VANCOMYCIN CAP:125MG,25382269,CDM,250,RC,,,Outpatient,,,220,220,,,,,,Other,Not Separately Reimbursable,181.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,181.5,82.5,,145.2,percent of total billed charges,Pays at 82.5% of total Billed charges,160.6,73,,128.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154,70,,123.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,19.19,,33.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110,50,,88,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,181.5,
TOPIRAMATE(TOPAMAX)TAB:50MG,25382272,CDM,250,RC,,,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
DILTIAZEM(CARDIZEM)INJ 25MG:5ML,25382279,CDM,250,RC,,,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,23.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.1,82.5,,18.48,percent of total billed charges,Pays at 82.5% of total Billed charges,20.44,73,,16.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.6,70,,15.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,19.19,,4.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,50,,11.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,23.1,
MIDODRINE TAB:5MG,25382332,CDM,250,RC,,,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
BUSPIRONE TAB:10MG,25382368,CDM,636,RC,,,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
FENTANYL(DURAGESIC)PATCH:100MCG/HR,25382385,CDM,250,RC,J0885,HCPCS,Outpatient,,,321,321,,,,,,Other,Not Separately Reimbursable,264.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,264.83,82.5,,211.864,percent of total billed charges,Pays at 82.5% of total Billed charges,234.33,73,,187.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,224.7,70,,179.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,19.19,,49.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,160.5,50,,128.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,264.83,
"EPOETIN(PROCRIT) 40,000U:1ML",25382417,CDM,250,RC,,,Outpatient,,,2450,2450,,,,,,Other,Not Separately Reimbursable,2021.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2021.25,82.5,,1617,percent of total billed charges,Pays at 82.5% of total Billed charges,1788.5,73,,1430.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1715,70,,1372,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,470.16,19.19,,376.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1225,50,,980,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,470.16,2021.25,
DANTROLENE(REVONTO)INJ:20MG,25382420,CDM,250,RC,,,Outpatient,,,404,404,,,,,,Other,Not Separately Reimbursable,333.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,333.3,82.5,,266.64,percent of total billed charges,Pays at 82.5% of total Billed charges,294.92,73,,235.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,282.8,70,,226.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.53,19.19,,62.024,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,202,50,,161.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.53,333.3,
VALACYCLOVIR(VALTREX)TAB:500MG,25382422,CDM,250,RC,,,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,54.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,54.45,82.5,,43.56,percent of total billed charges,Pays at 82.5% of total Billed charges,48.18,73,,38.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.2,70,,36.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,19.19,,10.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33,50,,26.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,54.45,
SODIUM BICARB 4.2%SYRINGE:10ML,25382438,CDM,250,RC,J1650,HCPCS,Outpatient,,,96,96,,,,,,Other,Not Separately Reimbursable,79.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,79.2,82.5,,63.36,percent of total billed charges,Pays at 82.5% of total Billed charges,70.08,73,,56.064,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.2,70,,53.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,19.19,,14.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48,50,,38.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,79.2,
FONDAPARINUX(ARIXTRA)INJ:10MG,25382547,CDM,250,RC,,,Outpatient,,,544,544,,,,,,Other,Not Separately Reimbursable,448.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,448.8,82.5,,359.04,percent of total billed charges,Pays at 82.5% of total Billed charges,397.12,73,,317.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,380.8,70,,304.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.39,19.19,,83.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,272,50,,217.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.39,448.8,
HALOPERIDOL ORAL SYR 2MG:1ML,25382584,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
NEBIVOLOL(BYSTOLIC)TAB:5MG,25382600,CDM,250,RC,,,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,27.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.23,82.5,,21.784,percent of total billed charges,Pays at 82.5% of total Billed charges,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,27.23,
FENTANYL(DURAGESIC)PATCH:12MCG/HR,25382664,CDM,250,RC,S0020,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
BUPIVICAINE-PF/EPINEPH 0.5%:10ML,25382676,CDM,250,RC,,,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,23.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.1,82.5,,18.48,percent of total billed charges,Pays at 82.5% of total Billed charges,20.44,73,,16.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.6,70,,15.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,19.19,,4.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,50,,11.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,23.1,
DILTIAZEM(CARDIZEM)INJ:125MG/25ML,25382964,CDM,250,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
MEDROXYprogesterone IM SUSP 150MG/1ML,25383069,CDM,636,RC,,,Outpatient,,,402,402,,,,,,Other,Not Separately Reimbursable,331.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,331.65,82.5,,265.32,percent of total billed charges,Pays at 82.5% of total Billed charges,293.46,73,,234.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,281.4,70,,225.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.14,19.19,,61.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,201,50,,160.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.14,331.65,
NF-Methadone Tablet 10mg,25383138,CDM,250,RC,S0073,HCPCS,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,14.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.85,82.5,,11.88,percent of total billed charges,Pays at 82.5% of total Billed charges,13.14,73,,10.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,70,,10.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,19.19,,2.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9,50,,7.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,14.85,
AZTREONAM(AZACTAM)INJ:2GM,25383144,CDM,250,RC,,,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,165,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,165,82.5,,132,percent of total billed charges,Pays at 82.5% of total Billed charges,146,73,,116.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,70,,112,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,19.19,,30.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100,50,,80,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,165,
MAGIC MOUTHWASH : 15ML,25383155,CDM,250,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ONDANSETRON(ZOFRAN)INJ 16MG/50ML NS,25383262,CDM,636,RC,J0696,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CEFTRIAXONE IM ONLY(ROCEPHIN)INJ:500 MG,25383282,CDM,636,RC,Q9966,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
OMNIPAQUE LOCM 50 ML,25383289,CDM,255,RC,,,Outpatient,,,191,191,,,,,,Other,Not Separately Reimbursable,157.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,157.58,82.5,,126.064,percent of total billed charges,Pays at 82.5% of total Billed charges,139.43,73,,111.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133.7,70,,106.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.65,19.19,,29.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.5,50,,76.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.65,157.58,
IVERMECTIN TAB: 3MG,25383305,CDM,250,RC,J2250,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
MIDAZOLAM(VERSED)5MG/ML:10ML,25383400,CDM,250,RC,J2250,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
MIDAZOLAM(VERSED)SYRINGE 5MG/ML:1ML,25383401,CDM,250,RC,,,Outpatient,,,22,22,,,,,,Other,Not Separately Reimbursable,18.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.15,82.5,,14.52,percent of total billed charges,Pays at 82.5% of total Billed charges,16.06,73,,12.848,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.4,70,,12.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,19.19,,3.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11,50,,8.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,18.15,
DULOXETINE DR (CYMBALTA)CAP:60MG,25383464,CDM,250,RC,90670,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,57.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,57.75,82.5,,46.2,percent of total billed charges,Pays at 82.5% of total Billed charges,51.1,73,,40.88,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,70,,39.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,19.19,,10.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,50,,28,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.43,57.75,
PREVNAR-13(PNEUMOCOCCAL)VACCINE INJ:,25383521,CDM,636,RC,,,Outpatient,,,688,688,,,,,,Other,Not Separately Reimbursable,567.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,567.6,82.5,,454.08,percent of total billed charges,Pays at 82.5% of total Billed charges,502.24,73,,401.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,481.6,70,,385.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.03,19.19,,105.624,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,344,50,,275.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.03,567.6,
SUGAMMADEX(BRIDION) 200MG:2ML,25383966,CDM,250,RC,,,Outpatient,,,456,456,,,,,,Other,Not Separately Reimbursable,376.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,376.2,82.5,,300.96,percent of total billed charges,Pays at 82.5% of total Billed charges,332.88,73,,266.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,319.2,70,,255.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.51,19.19,,70.008,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,228,50,,182.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.51,376.2,
ACETAMIN/CODEINE(LIQUID):120/12MG/5ML,25383982,CDM,250,RC,,,Outpatient,,,8,8,,,,,,Other,Not Separately Reimbursable,6.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6.6,82.5,,5.28,percent of total billed charges,Pays at 82.5% of total Billed charges,5.84,73,,4.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.6,70,,4.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,19.19,,1.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4,50,,3.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,6.6,
RIFAMPIN CAP:300MG,25383996,CDM,250,RC,J2354,HCPCS,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,7.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,7.43,82.5,,5.944,percent of total billed charges,Pays at 82.5% of total Billed charges,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,7.43,
OCTREOTIDE INJ:500MCG,25384012,CDM,636,RC,J2354,HCPCS,Outpatient,,,144,144,,,,,,Other,Not Separately Reimbursable,118.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,118.8,82.5,,95.04,percent of total billed charges,Pays at 82.5% of total Billed charges,105.12,73,,84.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.8,70,,80.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.63,19.19,,22.104,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72,50,,57.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.63,118.8,
OCTREOTIDE 50MCG INJ:1ML,25384019,CDM,636,RC,J0561,HCPCS,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,23.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.1,82.5,,18.48,percent of total billed charges,Pays at 82.5% of total Billed charges,20.44,73,,16.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.6,70,,15.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,19.19,,4.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,50,,11.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,23.1,
"BICILLIN LA : 600,000 UNIT",25384059,CDM,250,RC,,,Outpatient,,,456,456,,,,,,Other,Not Separately Reimbursable,376.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,376.2,82.5,,300.96,percent of total billed charges,Pays at 82.5% of total Billed charges,332.88,73,,266.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,319.2,70,,255.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.51,19.19,,70.008,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,228,50,,182.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.51,376.2,
SILDENAFIL(REVATIO)TAB:20MG,25384083,CDM,250,RC,,,Outpatient,,,155,155,,,,,,Other,Not Separately Reimbursable,127.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,127.88,82.5,,102.304,percent of total billed charges,Pays at 82.5% of total Billed charges,113.15,73,,90.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108.5,70,,86.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.74,19.19,,23.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.5,50,,62,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.74,127.88,
TOLTERODINE(DETROL)TAB:2MG,25384219,CDM,250,RC,,,Outpatient,,,34,34,,,,,,Other,Not Separately Reimbursable,28.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.05,82.5,,22.44,percent of total billed charges,Pays at 82.5% of total Billed charges,24.82,73,,19.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,70,,19.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,19.19,,5.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17,50,,13.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.52,28.05,
LOSARTAN(COZAAR)TAB:100MG,25384281,CDM,250,RC,,,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,25.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,25.58,82.5,,20.464,percent of total billed charges,Pays at 82.5% of total Billed charges,22.63,73,,18.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.7,70,,17.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,19.19,,4.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.5,50,,12.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,25.58,
DILTIAZEM CD(CARDIZEM)CAP:240MG,25384309,CDM,250,RC,J0897,HCPCS,Outpatient,,,26,26,,,,,,Other,Not Separately Reimbursable,21.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,21.45,82.5,,17.16,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,73,,15.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.2,70,,14.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,19.19,,3.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13,50,,10.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,21.45,
PROLASTIN-C 5670MG,25384403,CDM,636,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
MORPHINE ER(MS CONTIN)TAB:15MG,25384406,CDM,250,RC,,,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,15.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,15.68,82.5,,12.544,percent of total billed charges,Pays at 82.5% of total Billed charges,13.87,73,,11.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.3,70,,10.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,19.19,,2.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.5,50,,7.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,15.68,
ETHYL ALCOHOL: 30ML,25384495,CDM,250,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
GABAPENTIN(NEURONTIN)TAB:600MG,25384601,CDM,250,RC,,,Outpatient,,,26,26,,,,,,Other,Not Separately Reimbursable,21.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,21.45,82.5,,17.16,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,73,,15.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.2,70,,14.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,19.19,,3.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13,50,,10.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,21.45,
VITAMIN D3(CHOLECALC)TAB:25MCG(1000IU),25384610,CDM,250,RC,,,Outpatient,,,4,4,,,,,,Other,Not Separately Reimbursable,3.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3.3,82.5,,2.64,percent of total billed charges,Pays at 82.5% of total Billed charges,2.92,73,,2.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.8,70,,2.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,19.19,,0.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2,50,,1.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.77,3.3,
WATER(TAP): 8OZ,25384620,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ARIPIPRAZOLE(ABILIFY)TAB:10MG,25384663,CDM,250,RC,,,Outpatient,,,225,225,,,,,,Other,Not Separately Reimbursable,185.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,185.63,82.5,,148.504,percent of total billed charges,Pays at 82.5% of total Billed charges,164.25,73,,131.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.5,70,,126,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,19.19,,34.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112.5,50,,90,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,185.63,
METOLAZONE(ZAROXOLYN)TAB:5MG,25384792,CDM,250,RC,,,Outpatient,,,16,16,,,,,,Other,Not Separately Reimbursable,13.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13.2,82.5,,10.56,percent of total billed charges,Pays at 82.5% of total Billed charges,11.68,73,,9.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.2,70,,8.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,19.19,,2.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8,50,,6.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,13.2,
TRIMETH/POLYMYX(POLYTRIM) OPTH:10ML,25384808,CDM,250,RC,,,Outpatient,,,129,129,,,,,,Other,Not Separately Reimbursable,106.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,106.43,82.5,,85.144,percent of total billed charges,Pays at 82.5% of total Billed charges,94.17,73,,75.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.3,70,,72.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.76,19.19,,19.808,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.5,50,,51.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.76,106.43,
KCL(POTASSIUM CL)ORAL PWD:20MEQ,25384836,CDM,250,RC,,,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
"ERGOCALCIFEROL(VIT D)LIQ CAP: 50,000IU",25384904,CDM,250,RC,90653,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
FLU(HIGH DOSE>65 YO)FLUAD VAC:0.5ML,25384913,CDM,636,RC,,,Outpatient,,,630,630,,,,,,Other,Not Separately Reimbursable,519.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,519.75,82.5,,415.8,percent of total billed charges,Pays at 82.5% of total Billed charges,459.9,73,,367.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,441,70,,352.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,120.9,19.19,,96.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,315,50,,252,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,120.9,519.75,
TUCKS HEMORRHOIDAL PAD 50%:100,25384921,CDM,250,RC,J0875,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DALBAVANCIN(DALVANCE)INJ:500MG,25385003,CDM,250,RC,,,Outpatient,,,5525,5525,,,,,,Other,Not Separately Reimbursable,4558.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4558.13,82.5,,3646.504,percent of total billed charges,Pays at 82.5% of total Billed charges,4033.25,73,,3226.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3867.5,70,,3094,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1060.25,19.19,,848.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2762.5,50,,2210,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1060.25,4558.13,
VALACYCLOVIR(VALTREX)TAB:1000MG,25385106,CDM,250,RC,J0282,HCPCS,Outpatient,,,102,102,,,,,,Other,Not Separately Reimbursable,84.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,84.15,82.5,,67.32,percent of total billed charges,Pays at 82.5% of total Billed charges,74.46,73,,59.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.4,70,,57.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,19.19,,15.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51,50,,40.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,84.15,
AMIODARONE INJ:450MG,25385203,CDM,636,RC,,,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
CMPD(Hydrocortisone/Sarna 1:1)CR,25385276,CDM,250,RC,,,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
QUEtiapine(SEROQUEL)TAB:200MG,25385287,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
THEOPHYLLINE ER TAB:600 MG,25385329,CDM,250,RC,J3360,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DIAZEPAM VIAL 5MG/ML:10ML,25385372,CDM,250,RC,,,Outpatient,,,248,248,,,,,,Other,Not Separately Reimbursable,204.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,204.6,82.5,,163.68,percent of total billed charges,Pays at 82.5% of total Billed charges,181.04,73,,144.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,173.6,70,,138.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.59,19.19,,38.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124,50,,99.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.59,204.6,
NEBIVOLOL(BYSTOLIC)TAB:2.5MG,25385379,CDM,250,RC,,,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
BUDESONIDE EC CAP: 3MG,25385388,CDM,250,RC,J2550,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
PROMETHAZINE 50MG INJ:1ML,25385601,CDM,250,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
LITHIUM CARB ER TAB:300MG,25385618,CDM,250,RC,,,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,9.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.9,82.5,,7.92,percent of total billed charges,Pays at 82.5% of total Billed charges,8.76,73,,7.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.4,70,,6.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,19.19,,1.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6,50,,4.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,9.9,
TETRACAINE 0.5% OPHTH SOLN: 4ML,25385677,CDM,250,RC,,,Outpatient,,,93,93,,,,,,Other,Not Separately Reimbursable,76.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,76.73,82.5,,61.384,percent of total billed charges,Pays at 82.5% of total Billed charges,67.89,73,,54.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.1,70,,52.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.85,19.19,,14.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.5,50,,37.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.85,76.73,
ATORVASTATIN(LIPITOR)TAB:40MG,25385801,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
RIVAROXABAN(XARELTO)TAB:20MG,25385803,CDM,250,RC,,,Outpatient,,,107,107,,,,,,Other,Not Separately Reimbursable,88.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,88.28,82.5,,70.624,percent of total billed charges,Pays at 82.5% of total Billed charges,78.11,73,,62.488,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.9,70,,59.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.53,19.19,,16.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.5,50,,42.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.53,88.28,
EYE WASH(COLLYRIUM):118ML,25385830,CDM,250,RC,J0712,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
CEFTAROLINE(TEFLARO)INJ:600MG,25385831,CDM,636,RC,J2020,HCPCS,Outpatient,,,1154,1154,,,,,,Other,Not Separately Reimbursable,952.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,952.05,82.5,,761.64,percent of total billed charges,Pays at 82.5% of total Billed charges,842.42,73,,673.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,807.8,70,,646.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,221.45,19.19,,177.16,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,577,50,,461.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,221.45,952.05,
LINEZOLID(ZYVOX)600MG/300ML D5W,25385842,CDM,636,RC,90632,HCPCS,Outpatient,,,672,672,,,,,,Other,Not Separately Reimbursable,554.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,554.4,82.5,,443.52,percent of total billed charges,Pays at 82.5% of total Billed charges,490.56,73,,392.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,470.4,70,,376.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.96,19.19,,103.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,336,50,,268.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.96,554.4,
Hepatitis A vaccination for adults,25385967,CDM,636,RC,90691,HCPCS,Outpatient,,,265,265,,,,,,Other,Not Separately Reimbursable,218.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,218.63,82.5,,174.904,percent of total billed charges,Pays at 82.5% of total Billed charges,193.45,73,,154.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,185.5,70,,148.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.85,19.19,,40.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.5,50,,106,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.85,218.63,
TYPHOID VACCINE 25MCG IM:0.5ML,25385968,CDM,636,RC,,,Outpatient,,,446,446,,,,,,Other,Not Separately Reimbursable,367.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,367.95,82.5,,294.36,percent of total billed charges,Pays at 82.5% of total Billed charges,325.58,73,,260.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,312.2,70,,249.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85.59,19.19,,68.472,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,223,50,,178.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85.59,367.95,
HYDROCORTISONE OINT 2.5%:20GM,25386035,CDM,250,RC,,,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,15.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,15.68,82.5,,12.544,percent of total billed charges,Pays at 82.5% of total Billed charges,13.87,73,,11.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.3,70,,10.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,19.19,,2.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.5,50,,7.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,15.68,
ATORVASTATIN(LIPITOR)TAB:20MG,25386165,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
rOPINIRole(REQUIP)TAB:0.25MG,25386271,CDM,250,RC,S0077,HCPCS,Outpatient,,,26,26,,,,,,Other,Not Separately Reimbursable,21.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,21.45,82.5,,17.16,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,73,,15.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.2,70,,14.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,19.19,,3.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13,50,,10.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,21.45,
CLINDAMYCIN(CLEOCIN)INJ:600MG,25386276,CDM,250,RC,J0692,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
CEFEPIME(MAXIPIME)2GM/50ML NS,25386298,CDM,250,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
CETIRIZINE ODT(PEDIATRIC):10MG,25386305,CDM,250,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
FUROSEMIDE(LASIX)TAB:80MG,25386398,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
XYLOCAINE(LIDOCAINE)MPF 2% INJ:2 ML,25386408,CDM,250,RC,,,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,64.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,64.35,82.5,,51.48,percent of total billed charges,Pays at 82.5% of total Billed charges,56.94,73,,45.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.6,70,,43.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,19.19,,11.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39,50,,31.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.97,64.35,
BISOPROLOL TAB:5MG,25386436,CDM,250,RC,,,Outpatient,,,26,26,,,,,,Other,Not Separately Reimbursable,21.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,21.45,82.5,,17.16,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,73,,15.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.2,70,,14.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,19.19,,3.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13,50,,10.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,21.45,
BISOPROLOL(ZEBETA)TAB:5MG,25386470,CDM,250,RC,J1170,HCPCS,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
HYDROmorphone INJ:0.5MG/0.5ML,25386648,CDM,250,RC,,,Outpatient,,,36,36,,,,,,Other,Not Separately Reimbursable,29.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,29.7,82.5,,23.76,percent of total billed charges,Pays at 82.5% of total Billed charges,26.28,73,,21.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.2,70,,20.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,19.19,,5.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18,50,,14.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,29.7,
ATENOLOL (TENORMIN) TAB: 50 MG,25386756,CDM,250,RC,J2997,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ALTEPLASE (ACTIVASE)INJ: 100 MG,25386794,CDM,636,RC,,,Outpatient,,,21754,21754,,,,,,Other,Not Separately Reimbursable,17947.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,17947.05,82.5,,14357.64,percent of total billed charges,Pays at 82.5% of total Billed charges,15880.42,73,,12704.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15227.8,70,,12182.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4174.59,19.19,,3339.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10877,50,,8701.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4174.59,17947.05,
LIDOCAINE(XYLOCAINE)MPF 1% INJ:2 ML,25386915,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
CHLORDIAZEPOXIDE(LIBRIUM)CAP:10MG,25387043,CDM,250,RC,,,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
CLINIMIX 5%/DEX 25% SOLN./CUSTOM:1L,25387084,CDM,250,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
POTASSIUM CHLORIDE INJ:40mEq/20ML,25387085,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
LIDOCAINE 1GM(4MG/ML)DRIP:250ML,25387104,CDM,250,RC,,,Outpatient,,,72,72,,,,,,Other,Not Separately Reimbursable,59.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,59.4,82.5,,47.52,percent of total billed charges,Pays at 82.5% of total Billed charges,52.56,73,,42.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.4,70,,40.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,19.19,,11.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36,50,,28.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,59.4,
GLYCOPYRROLATE(ROBINUL)TAB:1MG,25387126,CDM,250,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
MORPHINE SOLN.CONC.:10 MG/0.5ML,25387193,CDM,250,RC,90746,HCPCS,Outpatient,,,8,8,,,,,,Other,Not Separately Reimbursable,6.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6.6,82.5,,5.28,percent of total billed charges,Pays at 82.5% of total Billed charges,5.84,73,,4.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.6,70,,4.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,19.19,,1.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4,50,,3.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,6.6,
Hepatitis B vaccine,25387280,CDM,636,RC,,,Outpatient,,,412,412,,,,,,Other,Not Separately Reimbursable,339.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,339.9,82.5,,271.92,percent of total billed charges,Pays at 82.5% of total Billed charges,300.76,73,,240.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,288.4,70,,230.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.06,19.19,,63.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,206,50,,164.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.06,339.9,
metFORMIN(GLUCOPHAGE)TAB:1000MG,25387281,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
glipiZIDE XL(GLUCOTROL XL)TAB:10MG,25387282,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
SULFAMETH/TRIMETH(SEPTRA)SUSP:20 ML,25387295,CDM,250,RC,,,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,62.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,62.7,82.5,,50.16,percent of total billed charges,Pays at 82.5% of total Billed charges,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,62.7,
LIDOCAINE PF 1% INJ:5 ML,25387338,CDM,250,RC,J0256,HCPCS,Outpatient,,,27,27,,,,,,Other,Not Separately Reimbursable,22.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,22.28,82.5,,17.824,percent of total billed charges,Pays at 82.5% of total Billed charges,19.71,73,,15.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.9,70,,15.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,19.19,,4.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.5,50,,10.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,22.28,
PROLASTIN(ALPH-1)INJ:6160 MG,25387350,CDM,250,RC,,,Outpatient,,,4140,4140,,,,,,Other,Not Separately Reimbursable,3415.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3415.5,82.5,,2732.4,percent of total billed charges,Pays at 82.5% of total Billed charges,3022.2,73,,2417.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2898,70,,2318.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,794.47,19.19,,635.576,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2070,50,,1656,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,794.47,3415.5,
MUPIROCIN 2%(BACTROBAN)OINT:22GM,25387434,CDM,250,RC,,,Outpatient,,,137,137,,,,,,Other,Not Separately Reimbursable,113.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,113.03,82.5,,90.424,percent of total billed charges,Pays at 82.5% of total Billed charges,100.01,73,,80.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.9,70,,76.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.29,19.19,,21.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.5,50,,54.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.29,113.03,
PROPRANOLOL(INDERAL)TAB:20MG,25387435,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DONEPEZIL(ARICEPT)TAB:10MG,25387442,CDM,250,RC,,,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
ACETAMIN/CODEINE(LIQUID):300/30MG/12.5ML,25387493,CDM,250,RC,,,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
DOXEPIN HCL CAP:10MG,25387554,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
rOPINIRole(REQUIP)TAB:2MG,25387557,CDM,250,RC,J3260,HCPCS,Outpatient,,,26,26,,,,,,Other,Not Separately Reimbursable,21.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,21.45,82.5,,17.16,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,73,,15.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.2,70,,14.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,19.19,,3.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13,50,,10.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,21.45,
TOBRAMYCIN POWDER INJ:1.2GM,25387565,CDM,250,RC,,,Outpatient,,,500,500,,,,,,Other,Not Separately Reimbursable,412.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,412.5,82.5,,330,percent of total billed charges,Pays at 82.5% of total Billed charges,365,73,,292,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,350,70,,280,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.95,19.19,,76.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,250,50,,200,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.95,412.5,
Entresto Oral Tablet 97MG-103MG,25387576,CDM,250,RC,J1450,HCPCS,Outpatient,,,24,24,,,,,,Other,Not Separately Reimbursable,19.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,19.8,82.5,,15.84,percent of total billed charges,Pays at 82.5% of total Billed charges,17.52,73,,14.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.8,70,,13.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.61,19.19,,3.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12,50,,9.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.61,19.8,
FLUCONAZOLE(DIFLUCAN)800MG/400ML IVPB,25387660,CDM,250,RC,J1450,HCPCS,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,71.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,71.78,82.5,,57.424,percent of total billed charges,Pays at 82.5% of total Billed charges,63.51,73,,50.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.9,70,,48.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,19.19,,13.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.5,50,,34.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,71.78,
FLUCONAZOLE(DIFLUCAN)400MG/200ML IVPB,25387661,CDM,250,RC,,,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,71.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,71.78,82.5,,57.424,percent of total billed charges,Pays at 82.5% of total Billed charges,63.51,73,,50.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.9,70,,48.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,19.19,,13.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.5,50,,34.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.7,71.78,
CLINIMIX E 5% W/DEXTROSE 15%2000 ML,25387757,CDM,250,RC,,,Outpatient,,,682,682,,,,,,Other,Not Separately Reimbursable,562.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,562.65,82.5,,450.12,percent of total billed charges,Pays at 82.5% of total Billed charges,497.86,73,,398.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,477.4,70,,381.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,130.88,19.19,,104.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,341,50,,272.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,130.88,562.65,
INTRALIPID 20% 500 ML,25387758,CDM,250,RC,J0256,HCPCS,Outpatient,,,250,250,,,,,,Other,Not Separately Reimbursable,206.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,206.25,82.5,,165,percent of total billed charges,Pays at 82.5% of total Billed charges,182.5,73,,146,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,70,,140,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,19.19,,38.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125,50,,100,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,206.25,
NF-ZEMAIRA IV:6664MG,25387771,CDM,250,RC,J0692,HCPCS,Outpatient,,,6284,6284,,,,,,Other,Not Separately Reimbursable,5184.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5184.3,82.5,,4147.44,percent of total billed charges,Pays at 82.5% of total Billed charges,4587.32,73,,3669.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4398.8,70,,3519.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1205.9,19.19,,964.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3142,50,,2513.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1205.9,5184.3,
CEFEPIME(MAXIPIME)INJ:1GM,25387786,CDM,250,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
OXYCODONE(IMMEDIATE)TAB:20MG,25387820,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
ENEMA - FLEETS (GREEN),25387895,CDM,250,RC,90686,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
Flu shot-high dose for 2019-2020 flu season given by injection for people >65,25387915,CDM,636,RC,,,Outpatient,,,165,165,,,,,,Other,Not Separately Reimbursable,136.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,136.13,82.5,,108.904,percent of total billed charges,Pays at 82.5% of total Billed charges,120.45,73,,96.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.5,70,,92.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.66,19.19,,25.328,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.5,50,,66,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.66,136.13,
OFLOXACIN OTIC SOLN:0.3% 5ML,25387929,CDM,250,RC,90682,HCPCS,Outpatient,,,126,126,,,,,,Other,Not Separately Reimbursable,103.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,103.95,82.5,,83.16,percent of total billed charges,Pays at 82.5% of total Billed charges,91.98,73,,73.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.2,70,,70.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.18,19.19,,19.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,50,,50.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.18,103.95,
FLUBLOK(INFLUENZA VAC)PFS:0.5ML,25387936,CDM,636,RC,,,Outpatient,,,338,338,,,,,,Other,Not Separately Reimbursable,278.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,278.85,82.5,,223.08,percent of total billed charges,Pays at 82.5% of total Billed charges,246.74,73,,197.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,236.6,70,,189.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.86,19.19,,51.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,169,50,,135.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.86,278.85,
NF-Ranexa Extended-Release Tablet 1000MG,25387944,CDM,250,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
INFLIXIMAB(REMICADE)INJ:100MG,25388026,CDM,250,RC,,,Outpatient,,,4950,4950,,,,,,Other,Not Separately Reimbursable,4083.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4083.75,82.5,,3267,percent of total billed charges,Pays at 82.5% of total Billed charges,3613.5,73,,2890.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3465,70,,2772,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,949.91,19.19,,759.928,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2475,50,,1980,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,949.91,4083.75,
RANEXA(RANOLAZINE)ER TAB:500MG,25388173,CDM,250,RC,J0712,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
CEFTAROLINE(TEFLARO)INJ:600MG,25388279,CDM,636,RC,,,Outpatient,,,1264,1264,,,,,,Other,Not Separately Reimbursable,1042.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1042.8,82.5,,834.24,percent of total billed charges,Pays at 82.5% of total Billed charges,922.72,73,,738.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,884.8,70,,707.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,242.56,19.19,,194.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,632,50,,505.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,242.56,1042.8,
SPIRONOLACTONE(ALDACTONE)TAB:100MG,25388444,CDM,250,RC,,,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
PRIMIDONE TAB:250MG,25388493,CDM,250,RC,J0875,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DALBAVANCIN(DALVANCE)1125MG/250ML D5W,25388521,CDM,250,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
guaiFENesin LA(MUCINEX LA)TAB:1200MG,25388525,CDM,250,RC,J1756,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
VENOFER(IRON SUCROSE)200MG IN 100ML NS,25388562,CDM,636,RC,,,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
NEO-POLYCIN(NEO/POLY-B/BAC)OPTH OINT,25388620,CDM,250,RC,,,Outpatient,,,158,158,,,,,,Other,Not Separately Reimbursable,130.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,130.35,82.5,,104.28,percent of total billed charges,Pays at 82.5% of total Billed charges,115.34,73,,92.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110.6,70,,88.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.32,19.19,,24.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79,50,,63.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.32,130.35,
TOPIRAMATE(TOPAMAX)TAB:100MG,25388626,CDM,250,RC,J1756,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
VENOFER(IRON SUCROSE)500MG IN 250ML NS,25388627,CDM,636,RC,,,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
PHENAZOPYRIDINE (PYRIDIUM) TAB : 200MG,25388704,CDM,250,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
NF-methIMAzole Tablet 5MG,25388748,CDM,250,RC,,,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
NICARDIPINE(CARDENE)INJ 25MG:10ML,25388897,CDM,250,RC,,,Outpatient,,,218,218,,,,,,Other,Not Separately Reimbursable,179.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,179.85,82.5,,143.88,percent of total billed charges,Pays at 82.5% of total Billed charges,159.14,73,,127.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,152.6,70,,122.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.83,19.19,,33.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109,50,,87.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.83,179.85,
RISPERIDONE(RISPERDAL)TAB:0.5MG,25388907,CDM,250,RC,J2354,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
OCTREOTIDE 100MCG INJ:1ML,25388909,CDM,636,RC,J1439,HCPCS,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,23.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.1,82.5,,18.48,percent of total billed charges,Pays at 82.5% of total Billed charges,20.44,73,,16.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.6,70,,15.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,19.19,,4.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,50,,11.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,23.1,
INJECTAFER(FERRIC CARBOXY.)INJ: 750MG,25388914,CDM,636,RC,,,Outpatient,,,4620,4620,,,,,,Other,Not Separately Reimbursable,3811.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3811.5,82.5,,3049.2,percent of total billed charges,Pays at 82.5% of total Billed charges,3372.6,73,,2698.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3234,70,,2587.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,886.58,19.19,,709.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2310,50,,1848,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,886.58,3811.5,
ESMOLOL 100MG INJ:10ML,25388929,CDM,250,RC,,,Outpatient,,,128,128,,,,,,Other,Not Separately Reimbursable,105.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,105.6,82.5,,84.48,percent of total billed charges,Pays at 82.5% of total Billed charges,93.44,73,,74.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.6,70,,71.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,19.19,,19.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64,50,,51.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.56,105.6,
DRONEDARONE(MULTAQ)TAB:400MG,25388941,CDM,250,RC,,,Outpatient,,,106,106,,,,,,Other,Not Separately Reimbursable,87.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,87.45,82.5,,69.96,percent of total billed charges,Pays at 82.5% of total Billed charges,77.38,73,,61.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.2,70,,59.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.34,19.19,,16.272,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53,50,,42.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.34,87.45,
BUSPIRONE TAB:15MG,25388987,CDM,636,RC,,,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
apiXaban(ELIQUIS)TAB:2.5MG,25389026,CDM,250,RC,J0834,HCPCS,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
LEVOTHYROXINE(SYNTHROID)INJ:100MCG,25389027,CDM,636,RC,,,Outpatient,,,375,375,,,,,,Other,Not Separately Reimbursable,309.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,309.38,82.5,,247.504,percent of total billed charges,Pays at 82.5% of total Billed charges,273.75,73,,219,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,262.5,70,,210,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.96,19.19,,57.568,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,187.5,50,,150,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.96,309.38,
THEOPHYLLINE ER TAB:400 MG,25389044,CDM,250,RC,90746,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
Hepatitis B vaccine,25389302,CDM,636,RC,,,Outpatient,,,250,250,,,,,,Other,Not Separately Reimbursable,206.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,206.25,82.5,,165,percent of total billed charges,Pays at 82.5% of total Billed charges,182.5,73,,146,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,70,,140,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,19.19,,38.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125,50,,100,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,206.25,
NEOMYCIN-POLYMYXIN-DEX OPTH SUSP: 5ML,25389318,CDM,250,RC,J0885,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
"EPOETIN(PROCRIT) 20,000U:1ML",25389435,CDM,250,RC,,,Outpatient,,,1250,1250,,,,,,Other,Not Separately Reimbursable,1031.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1031.25,82.5,,825,percent of total billed charges,Pays at 82.5% of total Billed charges,912.5,73,,730,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,875,70,,700,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,239.88,19.19,,191.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,625,50,,500,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,239.88,1031.25,
ONDANSETRON(ZOFRAN)INJ 8MG/50ML NS,25389476,CDM,636,RC,S0020,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
MARCAINE(BUPIVICAINE)PF VIAL:0.75% 10ML,25389537,CDM,250,RC,J2185,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,26.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,26.4,82.5,,21.12,percent of total billed charges,Pays at 82.5% of total Billed charges,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,26.4,
MEROPENEM INJ:1GM,25389545,CDM,250,RC,,,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
SULFASALAZINE TAB:500MG,25389613,CDM,250,RC,,,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,9.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.9,82.5,,7.92,percent of total billed charges,Pays at 82.5% of total Billed charges,8.76,73,,7.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.4,70,,6.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,19.19,,1.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6,50,,4.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,9.9,
RECOTHROMBIN INJ:5000 UNITS,25389641,CDM,250,RC,,,Outpatient,,,620,620,,,,,,Other,Not Separately Reimbursable,511.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,511.5,82.5,,409.2,percent of total billed charges,Pays at 82.5% of total Billed charges,452.6,73,,362.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,434,70,,347.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,118.98,19.19,,95.184,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,310,50,,248,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,118.98,511.5,
"POLYMYXIN B VIAL:500,000UNIT",25389671,CDM,250,RC,J2795,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
ROPIVACAINE(NAROPIN)0.2%VIAL:10ML,25389676,CDM,250,RC,J2795,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
ROPIVACAINE(NAROPIN)0.5%VIAL:20ML,25389677,CDM,250,RC,,,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
NF-BRILINTA(ticagrelor)TAB:90MG,25389718,CDM,250,RC,J2260,HCPCS,Outpatient,,,125,125,,,,,,Other,Not Separately Reimbursable,103.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,103.13,82.5,,82.504,percent of total billed charges,Pays at 82.5% of total Billed charges,91.25,73,,73,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,70,,70,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,19.19,,19.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.5,50,,50,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,103.13,
MILRINONE RTU:40MG/200ML,25389742,CDM,636,RC,J2260,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,165,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,165,82.5,,132,percent of total billed charges,Pays at 82.5% of total Billed charges,146,73,,116.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,70,,112,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,19.19,,30.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100,50,,80,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,165,
MILRINONE RTU:20MG/100ML,25389798,CDM,636,RC,,,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,165,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,165,82.5,,132,percent of total billed charges,Pays at 82.5% of total Billed charges,146,73,,116.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,70,,112,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,19.19,,30.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100,50,,80,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,165,
BICALUTAMIDE(CASODEX)TAB: 50MG,25389812,CDM,250,RC,J0500,HCPCS,Outpatient,,,125,125,,,,,,Other,Not Separately Reimbursable,103.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,103.13,82.5,,82.504,percent of total billed charges,Pays at 82.5% of total Billed charges,91.25,73,,73,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,70,,70,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,19.19,,19.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.5,50,,50,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,103.13,
DICYCLOMINE(BENTYL) INJ: 20MG,25389863,CDM,636,RC,,,Outpatient,,,386,386,,,,,,Other,Not Separately Reimbursable,318.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,318.45,82.5,,254.76,percent of total billed charges,Pays at 82.5% of total Billed charges,281.78,73,,225.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,270.2,70,,216.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.07,19.19,,59.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,193,50,,154.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.07,318.45,
GENTAMICIN 0.1% OINT:15GM,25389905,CDM,250,RC,J1568,HCPCS,Outpatient,,,231,231,,,,,,Other,Not Separately Reimbursable,190.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,190.58,82.5,,152.464,percent of total billed charges,Pays at 82.5% of total Billed charges,168.63,73,,134.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161.7,70,,129.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.33,19.19,,35.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.5,50,,92.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.33,190.58,
OCTAGAM 10%(IVIG) 2 GRAM: 20 ML,25389920,CDM,636,RC,J1568,HCPCS,Outpatient,,,860,860,,,,,,Other,Not Separately Reimbursable,709.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,709.5,82.5,,567.6,percent of total billed charges,Pays at 82.5% of total Billed charges,627.8,73,,502.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,602,70,,481.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165.03,19.19,,132.024,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,430,50,,344,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165.03,709.5,
OCTAGAM 5%(IVIG) 1 GRAM: 20 ML,25389921,CDM,636,RC,J2997,HCPCS,Outpatient,,,360,360,,,,,,Other,Not Separately Reimbursable,297,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,297,82.5,,237.6,percent of total billed charges,Pays at 82.5% of total Billed charges,262.8,73,,210.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252,70,,201.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,19.19,,55.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180,50,,144,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,297,
ALTEPLASE (CATHFLO) INJ VIAL: 2 MG,25389953,CDM,636,RC,,,Outpatient,,,600,600,,,,,,Other,Not Separately Reimbursable,495,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,495,82.5,,396,percent of total billed charges,Pays at 82.5% of total Billed charges,438,73,,350.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,420,70,,336,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.14,19.19,,92.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,300,50,,240,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.14,495,
GUAIFENESIN/CODEINE(ROBITUSSIN AC):10ML,25390155,CDM,250,RC,J0878,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
DAPTOMYCIN(CUBICIN)INJ:350 MG,25390171,CDM,636,RC,Q5105,HCPCS,Outpatient,,,360,360,,,,,,Other,Not Separately Reimbursable,297,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,297,82.5,,237.6,percent of total billed charges,Pays at 82.5% of total Billed charges,262.8,73,,210.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252,70,,201.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,19.19,,55.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180,50,,144,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.08,297,
"EPOETIN(RETACRIT) 10,000U:1ML",25390238,CDM,250,RC,,,Outpatient,,,500,500,,,,,,Other,Not Separately Reimbursable,412.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,412.5,82.5,,330,percent of total billed charges,Pays at 82.5% of total Billed charges,365,73,,292,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,350,70,,280,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.95,19.19,,76.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,250,50,,200,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.95,412.5,
EXPAREL(BUPIVICAINE LIPO)PF 1.3%:20ML,25390278,CDM,250,RC,,,Outpatient,,,1675,1675,,,,,,Other,Not Separately Reimbursable,1381.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1381.88,82.5,,1105.504,percent of total billed charges,Pays at 82.5% of total Billed charges,1222.75,73,,978.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1172.5,70,,938,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,321.43,19.19,,257.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,837.5,50,,670,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,321.43,1381.88,
RITUXIMAB-ABBS(TRUXIMA)500MG:50ML,25390288,CDM,258,RC,,,Outpatient,,,17000,17000,,,,,,Other,Not Separately Reimbursable,14025,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14025,82.5,,11220,percent of total billed charges,Pays at 82.5% of total Billed charges,12410,73,,9928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11900,70,,9520,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3262.3,19.19,,2609.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8500,50,,6800,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3262.3,14025,
RITUXIMAB-ABBS(TRUXIMA)100MG:10ML,25390289,CDM,258,RC,Q5105,HCPCS,Outpatient,,,3400,3400,,,,,,Other,Not Separately Reimbursable,2805,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2805,82.5,,2244,percent of total billed charges,Pays at 82.5% of total Billed charges,2482,73,,1985.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2380,70,,1904,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,652.46,19.19,,521.968,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1700,50,,1360,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,652.46,2805,
"EPOETIN(RETACRIT) 40,000U:1ML",25390308,CDM,250,RC,J2407,HCPCS,Outpatient,,,2450,2450,,,,,,Other,Not Separately Reimbursable,2021.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2021.25,82.5,,1617,percent of total billed charges,Pays at 82.5% of total Billed charges,1788.5,73,,1430.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1715,70,,1372,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,470.16,19.19,,376.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1225,50,,980,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,470.16,2021.25,
ORITAVANCIN(ORBACTIV)INJ:400MG,25390309,CDM,250,RC,J1750,HCPCS,Outpatient,,,4900,4900,,,,,,Other,Not Separately Reimbursable,4042.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4042.5,82.5,,3234,percent of total billed charges,Pays at 82.5% of total Billed charges,3577,73,,2861.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3430,70,,2744,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,940.31,19.19,,752.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2450,50,,1960,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,940.31,4042.5,
INFED(IRON DEXTRAN)INJ:100MG,25390372,CDM,636,RC,J0841,HCPCS,Outpatient,,,316,316,,,,,,Other,Not Separately Reimbursable,260.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,260.7,82.5,,208.56,percent of total billed charges,Pays at 82.5% of total Billed charges,230.68,73,,184.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,221.2,70,,176.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.64,19.19,,48.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,158,50,,126.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.64,260.7,
ANAVIP(CROTALIDAE IMMUNE F):10 ML VIAL,25390471,CDM,250,RC,J1756,HCPCS,Outpatient,,,5856,5856,,,,,,Other,Not Separately Reimbursable,4831.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4831.2,82.5,,3864.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4274.88,73,,3419.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4099.2,70,,3279.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1123.77,19.19,,899.016,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2928,50,,2342.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1123.77,4831.2,
VENOFER(IRON SUCROSE)300MG IN 250ML NS,25390478,CDM,636,RC,,,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
HYDROXYchloroquine TAB:200MG,25390484,CDM,250,RC,J1568,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
OCTAGAM 10%(IVIG) 30 GRAM: 300 ML,25390497,CDM,636,RC,J1568,HCPCS,Outpatient,,,12900,12900,,,,,,Other,Not Separately Reimbursable,10642.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10642.5,82.5,,8514,percent of total billed charges,Pays at 82.5% of total Billed charges,9417,73,,7533.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9030,70,,7224,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2475.51,19.19,,1980.408,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6450,50,,5160,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2475.51,10642.5,
OCTAGAM 10%(IVIG) 20 GRAM: 200 ML,25390498,CDM,636,RC,,,Outpatient,,,8600,8600,,,,,,Other,Not Separately Reimbursable,7095,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,7095,82.5,,5676,percent of total billed charges,Pays at 82.5% of total Billed charges,6278,73,,5022.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6020,70,,4816,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1650.34,19.19,,1320.272,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4300,50,,3440,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1650.34,7095,
NF-SCOPOLAMINE TD PATCH 0.33MG/24HR,25390503,CDM,250,RC,,,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
MAGNESIUM SULFATE 1GM/100 ML INJECTION,25390504,CDM,250,RC,,,Outpatient,,,96,96,,,,,,Other,Not Separately Reimbursable,79.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,79.2,82.5,,63.36,percent of total billed charges,Pays at 82.5% of total Billed charges,70.08,73,,56.064,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.2,70,,53.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,19.19,,14.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48,50,,38.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.42,79.2,
TRANEXAMIC ACID INJ:1000MG,25390596,CDM,636,RC,,,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
DICYCLOMINE(BENTYL)TAB:20MG,25390597,CDM,250,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
ATORVASTATIN(LIPITOR)TAB:10MG,25390653,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
CARBIDOPA/LEVODOPA(SINEMET)TAB:25/250,25390669,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
CARBIDOPA/LEVODOPA(SINEMET)TAB:25/250,25390670,CDM,250,RC,,,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
CARBIDOPA/LEVODOPA(SINEMET)TAB:25/250,25390671,CDM,250,RC,J1250,HCPCS,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,10.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,10.73,82.5,,8.584,percent of total billed charges,Pays at 82.5% of total Billed charges,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,10.73,
DOBUTAMINE 250MG INJ:20ML,25390684,CDM,250,RC,J1250,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
DOBUTAMINE INJ: 250 MG IN 100 ML D5W,25390689,CDM,250,RC,,,Outpatient,,,124,124,,,,,,Other,Not Separately Reimbursable,102.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,102.3,82.5,,81.84,percent of total billed charges,Pays at 82.5% of total Billed charges,90.52,73,,72.416,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.8,70,,69.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,19.19,,19.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62,50,,49.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,102.3,
REMDESIVIR 100MG INJ: 20ML,25390700,CDM,636,RC,,,Outpatient,,,2500,2500,,,,,,Other,Not Separately Reimbursable,2062.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2062.5,82.5,,1650,percent of total billed charges,Pays at 82.5% of total Billed charges,1825,73,,1460,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1750,70,,1400,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,479.75,19.19,,383.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1250,50,,1000,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,479.75,2062.5,
OFIRMEV(ACETAMINOPHEN)1000MG INJ:100ML,25390802,CDM,250,RC,,,Outpatient,,,144,144,,,,,,Other,Not Separately Reimbursable,118.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,118.8,82.5,,95.04,percent of total billed charges,Pays at 82.5% of total Billed charges,105.12,73,,84.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.8,70,,80.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.63,19.19,,22.104,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72,50,,57.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.63,118.8,
PIOGLITAZONE(ACTOS)TAB:45 MG,25390805,CDM,250,RC,,,Outpatient,,,98,98,,,,,,Other,Not Separately Reimbursable,80.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,80.85,82.5,,64.68,percent of total billed charges,Pays at 82.5% of total Billed charges,71.54,73,,57.232,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68.6,70,,54.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.81,19.19,,15.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49,50,,39.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.81,80.85,
INSULIN DRIP(MYXREDLIN)RTU 1UNIT:1ML,25390813,CDM,250,RC,90632,HCPCS,Outpatient,,,240,240,,,,,,Other,Not Separately Reimbursable,198,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,198,82.5,,158.4,percent of total billed charges,Pays at 82.5% of total Billed charges,175.2,73,,140.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,168,70,,134.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.06,19.19,,36.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,120,50,,96,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.06,198,
Hepatitis A vaccination for adults,25390850,CDM,636,RC,,,Outpatient,,,265,265,,,,,,Other,Not Separately Reimbursable,218.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,218.63,82.5,,174.904,percent of total billed charges,Pays at 82.5% of total Billed charges,193.45,73,,154.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,185.5,70,,148.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.85,19.19,,40.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.5,50,,106,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.85,218.63,
CELLUVISC 1% EYE DROPS:0.4ML,25390851,CDM,250,RC,,,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
DEXMEDETOMIDINE(PRECEDEX)400MCG:100ML,25390876,CDM,250,RC,,,Outpatient,,,197,197,,,,,,Other,Not Separately Reimbursable,162.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,162.53,82.5,,130.024,percent of total billed charges,Pays at 82.5% of total Billed charges,143.81,73,,115.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.9,70,,110.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,19.19,,30.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.5,50,,78.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,162.53,
ALTEPLASE (CATHFLO) 2MG,25390882,CDM,636,RC,,,Outpatient,,,700,700,,,,,,Other,Not Separately Reimbursable,577.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,577.5,82.5,,462,percent of total billed charges,Pays at 82.5% of total Billed charges,511,73,,408.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,490,70,,392,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,134.33,19.19,,107.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,350,50,,280,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,134.33,577.5,
CILOSTAZOL TAB:100 MG,25390912,CDM,250,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
NF-SORE THROAT SPRAY 1.4%,25390921,CDM,250,RC,J0875,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
DALBAVANCIN(DALVANCE)1000MG/250ML D5W,25390928,CDM,250,RC,J0875,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
DALBAVANCIN(DALVANCE)500MG/250ML D5W,25390949,CDM,250,RC,J3370,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
VANCOMYCIN INJ 2000MG/400ML RTU,25390966,CDM,250,RC,J3370,HCPCS,Outpatient,,,382,382,,,,,,Other,Not Separately Reimbursable,315.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,315.15,82.5,,252.12,percent of total billed charges,Pays at 82.5% of total Billed charges,278.86,73,,223.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,267.4,70,,213.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.31,19.19,,58.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191,50,,152.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.31,315.15,
VANCOMYCIN INJ 1500MG/300ML RTU,25390975,CDM,250,RC,J3370,HCPCS,Outpatient,,,352,352,,,,,,Other,Not Separately Reimbursable,290.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,290.4,82.5,,232.32,percent of total billed charges,Pays at 82.5% of total Billed charges,256.96,73,,205.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,246.4,70,,197.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.55,19.19,,54.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176,50,,140.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.55,290.4,
VANCOMYCIN INJ 1000MG/200ML RTU,25390976,CDM,250,RC,J1568,HCPCS,Outpatient,,,322,322,,,,,,Other,Not Separately Reimbursable,265.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,265.65,82.5,,212.52,percent of total billed charges,Pays at 82.5% of total Billed charges,235.06,73,,188.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,225.4,70,,180.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.79,19.19,,49.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161,50,,128.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.79,265.65,
OCTAGAM 10%(IVIG) 10 GRAM: 100 ML,25391006,CDM,636,RC,J3370,HCPCS,Outpatient,,,4300,4300,,,,,,Other,Not Separately Reimbursable,3547.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,3547.5,82.5,,2838,percent of total billed charges,Pays at 82.5% of total Billed charges,3139,73,,2511.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3010,70,,2408,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,825.17,19.19,,660.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2150,50,,1720,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,825.17,3547.5,
VANCOMYCIN INJ 1250MG/250ML RTU,25391038,CDM,250,RC,,,Outpatient,,,322,322,,,,,,Other,Not Separately Reimbursable,265.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,265.65,82.5,,212.52,percent of total billed charges,Pays at 82.5% of total Billed charges,235.06,73,,188.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,225.4,70,,180.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.79,19.19,,49.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161,50,,128.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.79,265.65,
AMPHETAMINE SALTS(ADDERALL)TAB:5MG,25391076,CDM,250,RC,,,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
FLAVOXATE TAB:100MG,25391078,CDM,250,RC,,,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,20.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,20.63,82.5,,16.504,percent of total billed charges,Pays at 82.5% of total Billed charges,18.25,73,,14.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,70,,14,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,19.19,,3.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,50,,10,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,20.63,
ETHYL ALCOHOL(BEER):360ML,25391129,CDM,250,RC,S0030,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
metroNIDAZOLE(FLAGYL)IVPB:125MG,25391182,CDM,250,RC,,,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
FEBUXOSTAT TAB:40MG,25391201,CDM,250,RC,,,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
IRRIG NACL 3000ML BAG,26083515,CDM,270,RC,,,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,78.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,78.38,82.5,,62.704,percent of total billed charges,Pays at 82.5% of total Billed charges,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,78.38,
NORMOSOL R-1000,26085930,CDM,258,RC,,,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,38.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,38.78,82.5,,31.024,percent of total billed charges,Pays at 82.5% of total Billed charges,34.31,73,,27.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.9,70,,26.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,19.19,,7.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.5,50,,18.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,38.78,
HYPERTONIC SALINE 3%:500ML,26089026,CDM,270,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
NS 150ML,26089027,CDM,258,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
NS 250 ML,26089029,CDM,258,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
NS .45% 500ML,26089032,CDM,258,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
NS 500ML,26089034,CDM,258,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
NS 1000ML,26089036,CDM,258,RC,,,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,78.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,78.38,82.5,,62.704,percent of total billed charges,Pays at 82.5% of total Billed charges,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,78.38,
NS .45% 1000ML,26089037,CDM,258,RC,,,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,78.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,78.38,82.5,,62.704,percent of total billed charges,Pays at 82.5% of total Billed charges,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,78.38,
NS 100 ML,26089125,CDM,258,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
D5 1\2NS 500ML,26089126,CDM,258,RC,J7120,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
LR 500ML,26089127,CDM,258,RC,J7120,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
LR 250ML,26089128,CDM,258,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
D5 1\2NS 1000ML,26089129,CDM,258,RC,,,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,78.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,78.38,82.5,,62.704,percent of total billed charges,Pays at 82.5% of total Billed charges,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,78.38,
D5NS 500ML,26089226,CDM,258,RC,,,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,38.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,38.78,82.5,,31.024,percent of total billed charges,Pays at 82.5% of total Billed charges,34.31,73,,27.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.9,70,,26.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,19.19,,7.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.5,50,,18.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,38.78,
D5NS 1000ML,26089229,CDM,258,RC,J7120,HCPCS,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,78.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,78.38,82.5,,62.704,percent of total billed charges,Pays at 82.5% of total Billed charges,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,78.38,
LR 500ML,26089325,CDM,258,RC,,,Outpatient,,,63,63,,,,,,Other,Not Separately Reimbursable,51.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,51.98,82.5,,41.584,percent of total billed charges,Pays at 82.5% of total Billed charges,45.99,73,,36.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.1,70,,35.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,19.19,,9.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,50,,25.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.09,51.98,
LACTATED RINGERS: 1000ML,26089329,CDM,258,RC,,,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,78.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,78.38,82.5,,62.704,percent of total billed charges,Pays at 82.5% of total Billed charges,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,78.38,
D5LR 1000ML,26089429,CDM,258,RC,,,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,78.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,78.38,82.5,,62.704,percent of total billed charges,Pays at 82.5% of total Billed charges,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,78.38,
NORMALSOL 500ML,26089525,CDM,258,RC,,,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
NORMASOL 1000ML,26089529,CDM,258,RC,,,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
NORMAL SOL-R 1000ML,26089530,CDM,258,RC,,,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
D5W 100ML,26089625,CDM,258,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
D5W 150ML,26089626,CDM,258,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
D5W 250ML,26089627,CDM,258,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
D5W 1000ML,26089628,CDM,258,RC,,,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,78.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,78.38,82.5,,62.704,percent of total billed charges,Pays at 82.5% of total Billed charges,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,78.38,
D5W 50ML,26089630,CDM,258,RC,,,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
NS (BTL) 250ML,26089631,CDM,258,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
D5W 250ML,26089635,CDM,258,RC,,,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
D5W 500ML,26089640,CDM,258,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
D10W 500ML,26089800,CDM,258,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
D10W 1000ML,26089801,CDM,258,RC,,,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,78.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,78.38,82.5,,62.704,percent of total billed charges,Pays at 82.5% of total Billed charges,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,78.38,
3% NS 500ML HYPERTONIC,26089810,CDM,258,RC,,,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,38.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,38.78,82.5,,31.024,percent of total billed charges,Pays at 82.5% of total Billed charges,34.31,73,,27.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.9,70,,26.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,19.19,,7.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.5,50,,18.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,38.78,
D20 500ML,26089825,CDM,258,RC,,,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,38.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,38.78,82.5,,31.024,percent of total billed charges,Pays at 82.5% of total Billed charges,34.31,73,,27.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.9,70,,26.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,19.19,,7.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.5,50,,18.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,38.78,
D5\KCL 1000ML,26089925,CDM,258,RC,,,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,38.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,38.78,82.5,,31.024,percent of total billed charges,Pays at 82.5% of total Billed charges,34.31,73,,27.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.9,70,,26.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,19.19,,7.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.5,50,,18.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,38.78,
D5 .2NS 500ML,26089950,CDM,258,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
D5 NS 500ML,26089951,CDM,258,RC,,,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
31-60 MINUTES ANESTHESIA,27013002,CDM,370,RC,,,Outpatient,,,631,631,,,,,,Other,Not Separately Reimbursable,520.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,520.58,82.5,,416.464,percent of total billed charges,Pays at 82.5% of total Billed charges,460.63,73,,368.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,441.7,70,,353.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121.09,19.19,,96.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,315.5,50,,252.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121.09,520.58,
61-90 MINUTES ANESTHESIA,27013004,CDM,370,RC,,,Outpatient,,,696,696,,,,,,Other,Not Separately Reimbursable,574.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,574.2,82.5,,459.36,percent of total billed charges,Pays at 82.5% of total Billed charges,508.08,73,,406.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,487.2,70,,389.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133.56,19.19,,106.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,348,50,,278.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133.56,574.2,
91-120 MINUTES ANESTH,27013005,CDM,370,RC,,,Outpatient,,,862,862,,,,,,Other,Not Separately Reimbursable,711.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,711.15,82.5,,568.92,percent of total billed charges,Pays at 82.5% of total Billed charges,629.26,73,,503.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,603.4,70,,482.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165.42,19.19,,132.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,431,50,,344.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165.42,711.15,
EACH 30 MIN OVER 120 ANE,27013006,CDM,379,RC,,,Outpatient,,,103,103,,,,,,Other,Not Separately Reimbursable,84.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,84.98,82.5,,67.984,percent of total billed charges,Pays at 82.5% of total Billed charges,75.19,73,,60.152,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.1,70,,57.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.77,19.19,,15.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.5,50,,41.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.77,84.98,
MASK BIPAP MEDIUM,28002043,CDM,270,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
MASK BIPAP LARGE,28002075,CDM,270,RC,,,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
MASK BIPAP SMALL,28002077,CDM,270,RC,94060,HCPCS,Outpatient,,,110,110,,,,,,Other,Not Separately Reimbursable,90.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,90.75,82.5,,72.6,percent of total billed charges,Pays at 82.5% of total Billed charges,80.3,73,,64.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77,70,,61.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,19.19,,16.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55,50,,44,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.11,90.75,
Test to determine if wheezing is present,28008011,CDM,460,RC,94664,HCPCS,Outpatient,,,546,546,,,,,,Other,Not Separately Reimbursable,98.63,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,98.63,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,398.58,73,,318.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,382.2,70,,305.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.78,19.19,,83.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,273,50,,218.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.63,398.58,
IPPB/EzPAP INITIAL & SUBSEQUENT,28008037,CDM,460,RC,94640,HCPCS,Outpatient,,,101,101,,,,,,Other,Not Separately Reimbursable,83.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,83.33,82.5,,66.664,percent of total billed charges,Pays at 82.5% of total Billed charges,73.73,73,,58.984,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.7,70,,56.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,19.19,,15.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.5,50,,40.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,83.33,
"IPPB/EzPAP, SUBSEQUENT",28008045,CDM,410,RC,94640,HCPCS,Outpatient,,,118,118,,,,,,Other,Not Separately Reimbursable,97.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,97.35,82.5,,77.88,percent of total billed charges,Pays at 82.5% of total Billed charges,86.14,73,,68.912,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.6,70,,66.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,19.19,,18.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59,50,,47.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,97.35,
AEROSOL W/MEDS ALTERNATE SUBSEQUENT TX,28008052,CDM,410,RC,,,Outpatient,,,125,125,,,,,,Other,Not Separately Reimbursable,103.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,103.13,82.5,,82.504,percent of total billed charges,Pays at 82.5% of total Billed charges,91.25,73,,73,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,70,,70,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,19.19,,19.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.5,50,,50,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,103.13,
OXYGEN,28008060,CDM,271,RC,94010,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
Test to determine how well oxygen moves from the lungs to the blood stream,28008061,CDM,460,RC,,,Outpatient,,,155,155,,,,,,Other,Not Separately Reimbursable,44.79,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,44.79,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,113.15,73,,90.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108.5,70,,86.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.74,19.19,,23.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.5,50,,62,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.74,113.15,
OXYGEN PER HOUR 2,28008063,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
OXYGEN PER HOUR 3,28008064,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
OXYGEN PER HOUR 4,28008065,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
OXYGEN PER HOUR 5,28008066,CDM,271,RC,,,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
OXYGEN PER HOUR 6,28008067,CDM,271,RC,94664,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
FACE TENT/AEROSOL NEBULIZER,28008094,CDM,410,RC,94660,HCPCS,Outpatient,,,101,101,,,,,,Other,Not Separately Reimbursable,83.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,83.33,82.5,,66.664,percent of total billed charges,Pays at 82.5% of total Billed charges,73.73,73,,58.984,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.7,70,,56.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,19.19,,15.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.5,50,,40.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,83.33,
CPAP / BIPAP,28008111,CDM,410,RC,94762,HCPCS,Outpatient,,,527,527,,,,,,Other,Not Separately Reimbursable,434.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,434.78,82.5,,347.824,percent of total billed charges,Pays at 82.5% of total Billed charges,384.71,73,,307.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,368.9,70,,295.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.13,19.19,,80.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,263.5,50,,210.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.13,434.78,
PULSE OXIMETRY PER DAY,28008113,CDM,460,RC,94664,HCPCS,Outpatient,,,402,402,,,,,,Other,Not Separately Reimbursable,294.75,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,294.75,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,293.46,73,,234.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,281.4,70,,225.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.14,19.19,,61.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,201,50,,160.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.14,294.75,
CONT NEB INITIAL / EVALUATION,28008114,CDM,410,RC,94644,HCPCS,Outpatient,,,101,101,,,,,,Other,Not Separately Reimbursable,83.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,83.33,82.5,,66.664,percent of total billed charges,Pays at 82.5% of total Billed charges,73.73,73,,58.984,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.7,70,,56.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,19.19,,15.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.5,50,,40.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,83.33,
AEROSOL TREATMENT CONTINUOUS,28008115,CDM,410,RC,94150,HCPCS,Outpatient,,,125,125,,,,,,Other,Not Separately Reimbursable,103.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,103.13,82.5,,82.504,percent of total billed charges,Pays at 82.5% of total Billed charges,91.25,73,,73,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,70,,70,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,19.19,,19.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.5,50,,50,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,103.13,
NIF/VITAL CAPACITY,28008116,CDM,460,RC,94645,HCPCS,Outpatient,,,123,123,,,,,,Other,Not Separately Reimbursable,101.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,101.48,82.5,,81.184,percent of total billed charges,Pays at 82.5% of total Billed charges,89.79,73,,71.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.1,70,,68.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.6,19.19,,18.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.5,50,,49.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.6,101.48,
CONT AEROSOL PER HR 2,28008117,CDM,410,RC,94645,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,27.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.23,82.5,,21.784,percent of total billed charges,Pays at 82.5% of total Billed charges,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,27.23,
CONT AEROSOL PER HR 3,28008118,CDM,410,RC,94645,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,27.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.23,82.5,,21.784,percent of total billed charges,Pays at 82.5% of total Billed charges,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,27.23,
CONT AEROSOL PER HR 4,28008119,CDM,410,RC,94645,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,27.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.23,82.5,,21.784,percent of total billed charges,Pays at 82.5% of total Billed charges,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,27.23,
CONT AEROSOL PER HR 5,28008120,CDM,410,RC,94645,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,27.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.23,82.5,,21.784,percent of total billed charges,Pays at 82.5% of total Billed charges,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,27.23,
CONT AEROSOL PER HR 6,28008121,CDM,410,RC,36600,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,27.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.23,82.5,,21.784,percent of total billed charges,Pays at 82.5% of total Billed charges,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,27.23,
ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD,28008181,CDM,301,RC,94760,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
PULSE OX SPOT CHECK,28008184,CDM,460,RC,82803,HCPCS,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,67.13,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,67.13,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,73,
Test to measure arterial blood gases,28008185,CDM,301,RC,94761,HCPCS,Outpatient,,,330,330,,,,,,Other,Not Separately Reimbursable,86.53,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,86.53,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,240.9,73,,192.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,231,70,,184.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.33,19.19,,50.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165,50,,132,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.33,240.9,
6 MINUTE WALK TEST,28008188,CDM,460,RC,94760,HCPCS,Outpatient,,,283,283,,,,,,Other,Not Separately Reimbursable,174.98,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,174.98,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,206.59,73,,165.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,198.1,70,,158.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.31,19.19,,43.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,141.5,50,,113.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.31,206.59,
PULSE OX CONTINUOUS,28008189,CDM,460,RC,94668,HCPCS,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,67.13,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,67.13,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,67.13,
CPT SUBSEQUENT,28008193,CDM,410,RC,94664,HCPCS,Outpatient,,,126,126,,,,,,Other,Not Separately Reimbursable,103.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,103.95,82.5,,83.16,percent of total billed charges,Pays at 82.5% of total Billed charges,91.98,73,,73.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.2,70,,70.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.18,19.19,,19.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,50,,50.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.18,103.95,
AEROSOL SETUP AND INITIAL TREATMENT,28008201,CDM,410,RC,94200,HCPCS,Outpatient,,,101,101,,,,,,Other,Not Separately Reimbursable,83.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,83.33,82.5,,66.664,percent of total billed charges,Pays at 82.5% of total Billed charges,73.73,73,,58.984,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.7,70,,56.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,19.19,,15.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.5,50,,40.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,83.33,
INCENTIVE SPIROMETRY,28008262,CDM,460,RC,31500,HCPCS,Outpatient,,,232,232,,,,,,Other,Not Separately Reimbursable,27.18,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,27.18,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,169.36,73,,135.488,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,162.4,70,,129.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.52,19.19,,35.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116,50,,92.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.18,169.36,
INTUBATION ENDOTRACHEAL,28008263,CDM,410,RC,89220,HCPCS,Outpatient,,,539,539,,,,,,Other,Not Separately Reimbursable,444.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,444.68,82.5,,355.744,percent of total billed charges,Pays at 82.5% of total Billed charges,393.47,73,,314.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,377.3,70,,301.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.43,19.19,,82.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,269.5,50,,215.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103.43,444.68,
SPUTUM SPECIMEN,28008321,CDM,300,RC,94375,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
Graphical representation of inspiration and expiration,28008328,CDM,460,RC,94003,HCPCS,Outpatient,,,101,101,,,,,,Other,Not Separately Reimbursable,50.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,50.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,73.73,73,,58.984,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.7,70,,56.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,19.19,,15.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.5,50,,40.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,73.73,
VENT (LIFE SUPP)/ INITIAL DAY,28008329,CDM,410,RC,94640,HCPCS,Outpatient,,,933,933,,,,,,Other,Not Separately Reimbursable,769.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,769.73,82.5,,615.784,percent of total billed charges,Pays at 82.5% of total Billed charges,681.09,73,,544.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,653.1,70,,522.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.04,19.19,,143.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,466.5,50,,373.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.04,769.73,
AEROSOL SUBSEQUENT TREATMENTS,28008330,CDM,410,RC,94640,HCPCS,Outpatient,,,118,118,,,,,,Other,Not Separately Reimbursable,97.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,97.35,82.5,,77.88,percent of total billed charges,Pays at 82.5% of total Billed charges,86.14,73,,68.912,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.6,70,,66.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,19.19,,18.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59,50,,47.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,97.35,
INDUCED SPUTUM VIA AEROSOL,28008350,CDM,410,RC,94667,HCPCS,Outpatient,,,108,108,,,,,,Other,Not Separately Reimbursable,89.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,89.1,82.5,,71.28,percent of total billed charges,Pays at 82.5% of total Billed charges,78.84,73,,63.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75.6,70,,60.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.73,19.19,,16.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54,50,,43.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.73,89.1,
CPT (FLUTTER VALVE) INITIAL,28008352,CDM,410,RC,92950,HCPCS,Outpatient,,,136,136,,,,,,Other,Not Separately Reimbursable,112.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,112.2,82.5,,89.76,percent of total billed charges,Pays at 82.5% of total Billed charges,99.28,73,,79.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.2,70,,76.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.1,19.19,,20.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,68,50,,54.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.1,112.2,
"HEART/LUNG RESUSITATION, CPR",28008354,CDM,410,RC,93041,HCPCS,Outpatient,,,852,852,,,,,,Other,Not Separately Reimbursable,702.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,702.9,82.5,,562.32,percent of total billed charges,Pays at 82.5% of total Billed charges,621.96,73,,497.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,596.4,70,,477.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.5,19.19,,130.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,426,50,,340.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.5,702.9,
"RHYTHM ECG, TRACING",28008356,CDM,730,RC,94002,HCPCS,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,37.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,37.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,69.35,
VENTILATOR INITIATION / MANAGEMENT,28008360,CDM,410,RC,94150,HCPCS,Outpatient,,,933,933,,,,,,Other,Not Separately Reimbursable,769.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,769.73,82.5,,615.784,percent of total billed charges,Pays at 82.5% of total Billed charges,681.09,73,,544.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,653.1,70,,522.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.04,19.19,,143.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,466.5,50,,373.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.04,769.73,
"VITAL CAPACITY,TOTAL;PEAK FLOW",28094150,CDM,460,RC,94640,HCPCS,Outpatient,,,124,124,,,,,,Other,Not Separately Reimbursable,102.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,102.3,82.5,,81.84,percent of total billed charges,Pays at 82.5% of total Billed charges,90.52,73,,72.416,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.8,70,,69.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,19.19,,19.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62,50,,49.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,102.3,
MDI SUBSEQUENT TREATMENTS,28094640,CDM,410,RC,94664,HCPCS,Outpatient,,,118,118,,,,,,Other,Not Separately Reimbursable,97.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,97.35,82.5,,77.88,percent of total billed charges,Pays at 82.5% of total Billed charges,86.14,73,,68.912,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.6,70,,66.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,19.19,,18.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59,50,,47.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,97.35,
MDI SETUP AND INITIAL TREATMENT,28094664,CDM,410,RC,G0283,HCPCS,Outpatient,,,101,101,,,,,,Other,Not Separately Reimbursable,83.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,83.33,82.5,,66.664,percent of total billed charges,Pays at 82.5% of total Billed charges,73.73,73,,58.984,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.7,70,,56.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,19.19,,15.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.5,50,,40.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.38,83.33,
ELECTRIC STIMULATION UNATTENDED (KX),29004483,CDM,420,RC,97760,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"JOBST MEASUREMENT, 15 MIN",29014223,CDM,420,RC,97010,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
Use of external hot or cold packs,29014240,CDM,420,RC,97012,HCPCS,Outpatient,,,82,82,,,,,,Other,Not Separately Reimbursable,67.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,67.65,82.5,,54.12,percent of total billed charges,Pays at 82.5% of total Billed charges,59.86,73,,47.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.4,70,,45.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,19.19,,12.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41,50,,32.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,67.65,
Form of decompression therapy of the spine,29014241,CDM,420,RC,97014,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
One time use unattended,29014242,CDM,420,RC,97016,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",29014243,CDM,420,RC,97018,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
PARAFFIN BATH THERAPY,29014244,CDM,420,RC,97032,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
Repeated application to one or more parts of the body,29014261,CDM,420,RC,97033,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,29014262,CDM,420,RC,97035,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",29014265,CDM,420,RC,G0281,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
ULTRASOUND/E STIM 15 MIN,29014266,CDM,420,RC,97110,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",29014280,CDM,420,RC,97112,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
A technique used by physical therapists to restore normal body movement patterns,29014281,CDM,420,RC,97113,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
Use of water for therapy/exercises,29014282,CDM,420,RC,97116,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
A type of physical therapy,29014283,CDM,420,RC,97124,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
Use of massage,29014284,CDM,420,RC,97140,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
Manipulation of 1 or more regions of the body,29014285,CDM,420,RC,97542,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"WHEELCHAIR MANAGEMENT, 15 MIN",29014287,CDM,420,RC,97530,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",29014289,CDM,420,RC,97535,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
Occupational therapy,29014291,CDM,420,RC,97761,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"PROSTHETIC TRAINING, 15 MIN",29014299,CDM,420,RC,97760,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"ORTHOTIC TRAINING, 15 MIN",29014302,CDM,420,RC,97542,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
WHEELCHAIR EVALUATION AND FITTING,29014378,CDM,420,RC,97116,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"GAIT TRAINING THERAPY (59 MOD), 15 MIN",29014383,CDM,420,RC,97530,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"THERAPEUTIC ACTIVITIES (59 MOD), 15 MIN",29014389,CDM,420,RC,97760,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"ORTHOTIC TRAINING, 15 MIN (KX)",29014402,CDM,420,RC,97760,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"JOBST MEASUREMENT (KX), 15 MIN",29014423,CDM,420,RC,97014,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
ELECTRIC STIM UNATTENDED THERAPY-KX,29014442,CDM,420,RC,97016,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"Machines designed to pump cold water into an inflatable wrap or brace, compressing the enveloped area of the body",29014443,CDM,420,RC,97032,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
Repeated application to one or more parts of the body,29014461,CDM,420,RC,97035,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"ULTRASOUND THERAPY, 15 MIN (KX)",29014465,CDM,420,RC,97542,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
WHEELCHAIR EVALUATION AND FITTING (KX),29014478,CDM,420,RC,97110,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"THERAPUETIC EXERCISES (KX), 15 MIN",29014480,CDM,420,RC,97112,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"NEUROMUSCULAR RE-REDUCTION (KX), 15 MIN",29014481,CDM,420,RC,97113,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"AQUATIC THERAPY/EXERCISES (KX), 15 MIN",29014482,CDM,420,RC,97116,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"GAIT TRAINING THERAPY (KX), 15 MIN",29014483,CDM,420,RC,97124,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"MASSAGE THERAPY (KX), 15 MIN",29014484,CDM,420,RC,97140,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"MANUAL THERAPY (KX), 15 MIN",29014485,CDM,420,RC,97542,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"WHEELCHAIR MANAGEMENT (KX), 15 MIN",29014487,CDM,420,RC,97530,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"THERAPEUTIC ACTIVITIES (KX), 15 MIN",29014489,CDM,420,RC,97535,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"SELFCARE MGMT TRAINING (KX), 15 MIN",29014491,CDM,420,RC,97761,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"PROSTHETIC TRAINING (KX), 15 MIN",29014499,CDM,420,RC,97530,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",29014589,CDM,420,RC,97150,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
GROUP THERAPEUTIC PROCEDURES,29014888,CDM,420,RC,29580,HCPCS,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
APPLICATION OF PASTE/UNNA BOOT,29029580,CDM,420,RC,29580,HCPCS,Outpatient,,,220,220,,,,,,Other,Not Separately Reimbursable,181.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,181.5,82.5,,145.2,percent of total billed charges,Pays at 82.5% of total Billed charges,160.6,73,,128.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154,70,,123.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,19.19,,33.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110,50,,88,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,181.5,
APPLICATION OF PASTE/UNNA BOOT,29049580,CDM,510,RC,97026,HCPCS,Outpatient,,,220,220,,,,,,Other,Not Separately Reimbursable,181.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,181.5,82.5,,145.2,percent of total billed charges,Pays at 82.5% of total Billed charges,160.6,73,,128.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154,70,,123.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,19.19,,33.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110,50,,88,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.22,181.5,
Light-based method to treat pain and inflammation,29097026,CDM,420,RC,97161,HCPCS,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
"PT EVALUATION;LOW COMPLEX,20 MIN",29097161,CDM,420,RC,97162,HCPCS,Outpatient,,,266,266,,,,,,Other,Not Separately Reimbursable,219.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,219.45,82.5,,175.56,percent of total billed charges,Pays at 82.5% of total Billed charges,194.18,73,,155.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.2,70,,148.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,19.19,,40.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,50,,106.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,219.45,
"PT EVALUATION;MOD COMPLEX,30 MIN",29097162,CDM,424,RC,97163,HCPCS,Outpatient,,,266,266,,,,,,Other,Not Separately Reimbursable,219.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,219.45,82.5,,175.56,percent of total billed charges,Pays at 82.5% of total Billed charges,194.18,73,,155.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.2,70,,148.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,19.19,,40.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,50,,106.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,219.45,
"PT EVALUATION;HIGH COMPLEX,30 MIN",29097163,CDM,420,RC,97164,HCPCS,Outpatient,,,266,266,,,,,,Other,Not Separately Reimbursable,219.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,219.45,82.5,,175.56,percent of total billed charges,Pays at 82.5% of total Billed charges,194.18,73,,155.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.2,70,,148.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,19.19,,40.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,50,,106.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,219.45,
PT RE-EVALUATION; 20 MIN,29097164,CDM,420,RC,97161,HCPCS,Outpatient,,,133,133,,,,,,Other,Not Separately Reimbursable,109.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,109.73,82.5,,87.784,percent of total billed charges,Pays at 82.5% of total Billed charges,97.09,73,,77.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.1,70,,74.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.52,19.19,,20.416,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,50,,53.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.52,109.73,
"PT EVALUATION;LOW COMPLEX,20 MIN (KX)",29197161,CDM,420,RC,97162,HCPCS,Outpatient,,,266,266,,,,,,Other,Not Separately Reimbursable,219.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,219.45,82.5,,175.56,percent of total billed charges,Pays at 82.5% of total Billed charges,194.18,73,,155.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.2,70,,148.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,19.19,,40.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,50,,106.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,219.45,
"PT EVALUATION;MOD COMPLEX,30 MIN (KX)",29197162,CDM,424,RC,97163,HCPCS,Outpatient,,,266,266,,,,,,Other,Not Separately Reimbursable,219.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,219.45,82.5,,175.56,percent of total billed charges,Pays at 82.5% of total Billed charges,194.18,73,,155.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.2,70,,148.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,19.19,,40.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,50,,106.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,219.45,
"PT EVALUATION;HIGH COMPLEX,30 MIN (KX)",29197163,CDM,420,RC,97164,HCPCS,Outpatient,,,266,266,,,,,,Other,Not Separately Reimbursable,219.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,219.45,82.5,,175.56,percent of total billed charges,Pays at 82.5% of total Billed charges,194.18,73,,155.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.2,70,,148.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,19.19,,40.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,50,,106.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,219.45,
PT RE-EVALUATION; 20 MIN (KX),29197164,CDM,420,RC,G0515,HCPCS,Outpatient,,,133,133,,,,,,Other,Not Separately Reimbursable,109.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,109.73,82.5,,87.784,percent of total billed charges,Pays at 82.5% of total Billed charges,97.09,73,,77.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.1,70,,74.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.52,19.19,,20.416,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,50,,53.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.52,109.73,
"ST DEVELOPMENT OF COGN SKILLS, EA 15 MIN",30000515,CDM,440,RC,92610,HCPCS,Outpatient,,,354,354,,,,,,Other,Not Separately Reimbursable,292.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,292.05,82.5,,233.64,percent of total billed charges,Pays at 82.5% of total Billed charges,258.42,73,,206.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,247.8,70,,198.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,19.19,,54.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177,50,,141.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,292.05,
ST ASSESS OF SWALLOW FUNC,30026025,CDM,444,RC,92507,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
Therapy for speech or hearing,30026080,CDM,440,RC,92610,HCPCS,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
ST DYSPHAGIA RE-EVALUATION,30072610,CDM,444,RC,92526,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
ST DYSPHAGIA THERAPY,30082526,CDM,440,RC,92610,HCPCS,Outpatient,,,354,354,,,,,,Other,Not Separately Reimbursable,292.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,292.05,82.5,,233.64,percent of total billed charges,Pays at 82.5% of total Billed charges,258.42,73,,206.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,247.8,70,,198.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,19.19,,54.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177,50,,141.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,292.05,
ST DYSPHAGIA EVALUATION,30082610,CDM,444,RC,92521,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
ST EVAL- FLUENCY,30092521,CDM,444,RC,92522,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
ST EVAL- SOUND PRODUCTION,30092522,CDM,444,RC,92523,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
Evaluation of speech sound production with evaluation of language comprehension,30092523,CDM,444,RC,92524,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
ST EVAL-BEHAV/QUAL ANALY VOICE/RESONANC,30092524,CDM,444,RC,92526,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
ST TREATMENT OF SWALL DYSF,30092526,CDM,440,RC,92610,HCPCS,Outpatient,,,354,354,,,,,,Other,Not Separately Reimbursable,292.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,292.05,82.5,,233.64,percent of total billed charges,Pays at 82.5% of total Billed charges,258.42,73,,206.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,247.8,70,,198.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,19.19,,54.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177,50,,141.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,292.05,
ST DYSPHASIA EVAL ORAL/PHARYNG SWALLOWIN,30092610,CDM,444,RC,92612,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
ST FLEXIBLE FIBEROPTIC ENDOS EVAL,30092612,CDM,444,RC,97127,HCPCS,Outpatient,,,470,470,,,,,,Other,Not Separately Reimbursable,387.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,387.75,82.5,,310.2,percent of total billed charges,Pays at 82.5% of total Billed charges,343.1,73,,274.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329,70,,263.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,19.19,,72.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,235,50,,188,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,387.75,
"ST DEVELOPMENT OF COGN SKILLS, EA 15 MIN",30097127,CDM,440,RC,97129,HCPCS,Outpatient,,,354,354,,,,,,Other,Not Separately Reimbursable,292.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,292.05,82.5,,233.64,percent of total billed charges,Pays at 82.5% of total Billed charges,258.42,73,,206.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,247.8,70,,198.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,19.19,,54.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177,50,,141.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,292.05,
"ST DEVELOPMENT OF COGN SKILLS, EA 15 MIN",30097129,CDM,440,RC,97130,HCPCS,Outpatient,,,354,354,,,,,,Other,Not Separately Reimbursable,292.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,292.05,82.5,,233.64,percent of total billed charges,Pays at 82.5% of total Billed charges,258.42,73,,206.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,247.8,70,,198.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,19.19,,54.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177,50,,141.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,292.05,
"ST DEVELOPMENT OF COGN SKILLS, EA 15 MIN",30097130,CDM,440,RC,G0515,HCPCS,Outpatient,,,354,354,,,,,,Other,Not Separately Reimbursable,292.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,292.05,82.5,,233.64,percent of total billed charges,Pays at 82.5% of total Billed charges,258.42,73,,206.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,247.8,70,,198.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,19.19,,54.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177,50,,141.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,292.05,
"ST DEVELOPMENT COGN SKILLS, EA 15 MIN KX",30100515,CDM,440,RC,92610,HCPCS,Outpatient,,,354,354,,,,,,Other,Not Separately Reimbursable,292.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,292.05,82.5,,233.64,percent of total billed charges,Pays at 82.5% of total Billed charges,258.42,73,,206.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,247.8,70,,198.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,19.19,,54.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177,50,,141.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,292.05,
ST ASSESS OF SWALLOW FUNC(KX),30126025,CDM,444,RC,92507,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
ST VISIT (KX),30126080,CDM,440,RC,92523,HCPCS,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
Evaluation of speech sound production with evaluation of language comprehension,30192523,CDM,444,RC,92526,HCPCS,Outpatient,,,505,505,,,,,,Other,Not Separately Reimbursable,416.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,416.63,82.5,,333.304,percent of total billed charges,Pays at 82.5% of total Billed charges,368.65,73,,294.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,353.5,70,,282.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,19.19,,77.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.5,50,,202,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.91,416.63,
ST TREATMENT OF SWALL DYSF (KX MOD),30192526,CDM,440,RC,92612,HCPCS,Outpatient,,,354,354,,,,,,Other,Not Separately Reimbursable,292.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,292.05,82.5,,233.64,percent of total billed charges,Pays at 82.5% of total Billed charges,258.42,73,,206.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,247.8,70,,198.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,19.19,,54.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177,50,,141.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,292.05,
ST FLEXIBLE FIBEROPTIC ENDOS EVAL-KX MOD,30192612,CDM,444,RC,G0283,HCPCS,Outpatient,,,470,470,,,,,,Other,Not Separately Reimbursable,387.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,387.75,82.5,,310.2,percent of total billed charges,Pays at 82.5% of total Billed charges,343.1,73,,274.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329,70,,263.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,19.19,,72.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,235,50,,188,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.19,387.75,
OT ELECTRIC STIMULATION UNATTENDED THERA,31000283,CDM,430,RC,,,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT COBAN,31024067,CDM,271,RC,97750,HCPCS,Outpatient,,,8,8,,,,,,Other,Not Separately Reimbursable,6.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,6.6,82.5,,5.28,percent of total billed charges,Pays at 82.5% of total Billed charges,5.84,73,,4.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.6,70,,4.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,19.19,,1.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4,50,,3.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,6.6,
OT JOBST MEASURE/15MIN,31025023,CDM,430,RC,95852,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT RANGE OF MOTION HAND COMP,31025028,CDM,430,RC,97010,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
Use of external hot or cold packs,31025040,CDM,430,RC,G0281,HCPCS,Outpatient,,,82,82,,,,,,Other,Not Separately Reimbursable,67.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,67.65,82.5,,54.12,percent of total billed charges,Pays at 82.5% of total Billed charges,59.86,73,,47.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.4,70,,45.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,19.19,,12.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41,50,,32.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,67.65,
OT ELECT STIM UNATTEND,31025041,CDM,430,RC,97018,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
OT PARAFFIN BATH,31025043,CDM,430,RC,97032,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
Repeated application to one or more parts of the body,31025060,CDM,430,RC,97033,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
Psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders,31025061,CDM,430,RC,97035,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"Use of sound waves to treat medical problems, especially musculoskeletal problems like inflammation from injuries",31025064,CDM,430,RC,G0281,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT ULTRASOUND/E STIM EACH 15,31025065,CDM,430,RC,97110,HCPCS,Outpatient,,,61,61,,,,,,Other,Not Separately Reimbursable,50.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,50.33,82.5,,40.264,percent of total billed charges,Pays at 82.5% of total Billed charges,44.53,73,,35.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.7,70,,34.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,19.19,,9.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.5,50,,24.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,50.33,
"Therapeutic exercise to develop strength, endurance, range of motion, and flexibility, each 15 minutes",31025080,CDM,430,RC,97112,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
A technique used by physical therapists to restore normal body movement patterns,31025081,CDM,430,RC,97124,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
Use of massage,31025082,CDM,430,RC,97140,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
Manipulation of 1 or more regions of the body,31025083,CDM,430,RC,97140,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
Manipulation of 1 or more regions of the body,31025084,CDM,430,RC,97542,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT WHEELCHAIR/MGT/TRAIN 15,31025085,CDM,430,RC,97530,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"Incorporates the use of multiple parameters, such as balance, strength, and range of motion, for a functional activity",31025087,CDM,430,RC,97535,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
Occupational therapy,31025089,CDM,430,RC,97762,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT ORTHOTIC PROSTH. 15,31025300,CDM,430,RC,97761,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT PROSTH. TRAIN 15 MIN,31025301,CDM,430,RC,97760,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT ORTHOTIC FIT/ TRAIN 15,31025302,CDM,430,RC,97035,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT ULTRASOUND EACH 15MIN,31026064,CDM,430,RC,97110,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT THERAP. EXER EACH 15 (KX),31026080,CDM,430,RC,97112,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT NEUROMUSCULAR RE/ED 15MIN (KX),31026081,CDM,430,RC,97140,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT MYOFACIAL RELEASE 15MIN (KX),31026083,CDM,430,RC,97140,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT JOINT MOBILIZ/15MIN (KX),31026084,CDM,430,RC,97542,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT WHEELCHAIR/MGT/TRAIN 15 (KX),31026085,CDM,430,RC,97530,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT THERAPY ACT/ISOKIN/EX 15 (KX),31026087,CDM,430,RC,97535,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT ADL SELFCARE/HOMEMGT/15MIN (KX),31026089,CDM,430,RC,97762,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"OT ORTHOTIC PROSTH (KX), 15 MIN",31026300,CDM,430,RC,97761,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"OT PROSTH TRAIN (KX), 15 MIN",31026301,CDM,430,RC,97530,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT THERAPY ACT/ISOKIN (59 MOD)/EX 15,31027087,CDM,430,RC,97535,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OT ADL SELFCARE/HOMEMGT (59 MOD)/15MIN,31027089,CDM,430,RC,97150,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
OCCUPATIONAL THERPAY GROUP SESSION,31088888,CDM,430,RC,97127,HCPCS,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
OT DEV COGNITIVE SKILLS EA 15 MIN,31097127,CDM,430,RC,97165,HCPCS,Outpatient,,,91,91,,,,,,Other,Not Separately Reimbursable,75.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,75.08,82.5,,60.064,percent of total billed charges,Pays at 82.5% of total Billed charges,66.43,73,,53.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.7,70,,50.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.46,19.19,,13.968,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,50,,36.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.46,75.08,
"OT EVALUATION; LOW COMPLEXTY, 30 MIN",31097165,CDM,434,RC,97166,HCPCS,Outpatient,,,266,266,,,,,,Other,Not Separately Reimbursable,219.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,219.45,82.5,,175.56,percent of total billed charges,Pays at 82.5% of total Billed charges,194.18,73,,155.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.2,70,,148.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,19.19,,40.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,50,,106.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,219.45,
"OT EVALUATION; MOD COMPLEXTY, 45 MIN",31097166,CDM,434,RC,97167,HCPCS,Outpatient,,,266,266,,,,,,Other,Not Separately Reimbursable,219.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,219.45,82.5,,175.56,percent of total billed charges,Pays at 82.5% of total Billed charges,194.18,73,,155.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.2,70,,148.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,19.19,,40.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,50,,106.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,219.45,
"OT EVALUATION;HIGH COMPLEXTY, 60 MIN",31097167,CDM,430,RC,97168,HCPCS,Outpatient,,,266,266,,,,,,Other,Not Separately Reimbursable,219.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,219.45,82.5,,175.56,percent of total billed charges,Pays at 82.5% of total Billed charges,194.18,73,,155.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.2,70,,148.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,19.19,,40.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,50,,106.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,219.45,
OT RE-EVALUATION; 30 MIN,31097168,CDM,434,RC,97763,HCPCS,Outpatient,,,266,266,,,,,,Other,Not Separately Reimbursable,219.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,219.45,82.5,,175.56,percent of total billed charges,Pays at 82.5% of total Billed charges,194.18,73,,155.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.2,70,,148.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,19.19,,40.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,50,,106.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,219.45,
PT ORTH/PROS MGMT/TRAINING EACH 15 MIN,31097763,CDM,420,RC,97165,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
"OT EVALUATION LOW COMPLEXTY, 30 MIN (KX)",31197165,CDM,434,RC,97166,HCPCS,Outpatient,,,266,266,,,,,,Other,Not Separately Reimbursable,219.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,219.45,82.5,,175.56,percent of total billed charges,Pays at 82.5% of total Billed charges,194.18,73,,155.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.2,70,,148.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,19.19,,40.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,50,,106.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,219.45,
OT EVALUATION; MOD COMPLEXTY 45 MIN (KX),31197166,CDM,434,RC,97167,HCPCS,Outpatient,,,266,266,,,,,,Other,Not Separately Reimbursable,219.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,219.45,82.5,,175.56,percent of total billed charges,Pays at 82.5% of total Billed charges,194.18,73,,155.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.2,70,,148.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,19.19,,40.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,50,,106.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,219.45,
OT EVALUATION;HIGH COMPLEXTY 60 MIN (KX),31197167,CDM,434,RC,97168,HCPCS,Outpatient,,,266,266,,,,,,Other,Not Separately Reimbursable,219.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,219.45,82.5,,175.56,percent of total billed charges,Pays at 82.5% of total Billed charges,194.18,73,,155.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.2,70,,148.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,19.19,,40.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,50,,106.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,219.45,
OT RE-EVALUATION; 30 MIN (KX),31197168,CDM,434,RC,97763,HCPCS,Outpatient,,,266,266,,,,,,Other,Not Separately Reimbursable,219.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,219.45,82.5,,175.56,percent of total billed charges,Pays at 82.5% of total Billed charges,194.18,73,,155.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.2,70,,148.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,19.19,,40.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,50,,106.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.05,219.45,
PT ORTH/PROS MGMT/TRAIN EACH 15 MIN (KX),31197763,CDM,420,RC,36430,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
BLOOD TRANSFUSION,32036430,CDM,391,RC,96360,HCPCS,Outpatient,,,1915,1915,,,,,,Other,Not Separately Reimbursable,1579.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,1579.88,82.5,,1263.904,percent of total billed charges,Pays at 82.5% of total Billed charges,1397.95,73,,1118.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1340.5,70,,1072.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,367.49,19.19,,293.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,957.5,50,,766,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,367.49,1579.88,
IV INF HYDRATION INIT 31M-1HR,32096360,CDM,761,RC,96361,HCPCS,Outpatient,,,936,936,,,,,,Other,Not Separately Reimbursable,772.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,772.2,82.5,,617.76,percent of total billed charges,Pays at 82.5% of total Billed charges,683.28,73,,546.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,655.2,70,,524.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.62,19.19,,143.696,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,468,50,,374.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.62,772.2,
IV INF HYDRATION ADDL HOUR,32096361,CDM,761,RC,96365,HCPCS,Outpatient,,,189,189,,,,,,Other,Not Separately Reimbursable,155.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,155.93,82.5,,124.744,percent of total billed charges,Pays at 82.5% of total Billed charges,137.97,73,,110.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.3,70,,105.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.27,19.19,,29.016,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.5,50,,75.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.27,155.93,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",32096365,CDM,761,RC,96366,HCPCS,Outpatient,,,936,936,,,,,,Other,Not Separately Reimbursable,772.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,772.2,82.5,,617.76,percent of total billed charges,Pays at 82.5% of total Billed charges,683.28,73,,546.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,655.2,70,,524.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.62,19.19,,143.696,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,468,50,,374.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.62,772.2,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-additional infusions",32096366,CDM,761,RC,96367,HCPCS,Outpatient,,,189,189,,,,,,Other,Not Separately Reimbursable,155.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,155.93,82.5,,124.744,percent of total billed charges,Pays at 82.5% of total Billed charges,137.97,73,,110.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,132.3,70,,105.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.27,19.19,,29.016,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.5,50,,75.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.27,155.93,
IV INF THER/PROPH ADDL SEQUENT,32096367,CDM,761,RC,96372,HCPCS,Outpatient,,,299,299,,,,,,Other,Not Separately Reimbursable,246.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,246.68,82.5,,197.344,percent of total billed charges,Pays at 82.5% of total Billed charges,218.27,73,,174.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,209.3,70,,167.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.38,19.19,,45.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.5,50,,119.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.38,246.68,
"INJECTION, SC/IM",32096372,CDM,761,RC,96374,HCPCS,Outpatient,,,299,299,,,,,,Other,Not Separately Reimbursable,246.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,246.68,82.5,,197.344,percent of total billed charges,Pays at 82.5% of total Billed charges,218.27,73,,174.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,209.3,70,,167.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.38,19.19,,45.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.5,50,,119.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.38,246.68,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-IV push",32096374,CDM,761,RC,96375,HCPCS,Outpatient,,,936,936,,,,,,Other,Not Separately Reimbursable,772.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,772.2,82.5,,617.76,percent of total billed charges,Pays at 82.5% of total Billed charges,683.28,73,,546.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,655.2,70,,524.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.62,19.19,,143.696,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,468,50,,374.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.62,772.2,
"Intravenous infusion, for treatment, prophylaxis, or diagnosis-new drug add on",32096375,CDM,761,RC,99195,HCPCS,Outpatient,,,158,158,,,,,,Other,Not Separately Reimbursable,130.35,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,130.35,82.5,,104.28,percent of total billed charges,Pays at 82.5% of total Billed charges,115.34,73,,92.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,110.6,70,,88.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.32,19.19,,24.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79,50,,63.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.32,130.35,
PHLEBOTOMY THER SPX,32099195,CDM,761,RC,25605,HCPCS,Outpatient,,,532,532,,,,,,Other,Not Separately Reimbursable,438.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,438.9,82.5,,351.12,percent of total billed charges,Pays at 82.5% of total Billed charges,388.36,73,,310.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,372.4,70,,297.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.09,19.19,,81.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,266,50,,212.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.09,438.9,
CLTX DSTL RDL FX/EPIPHYSL +-W/ MNP,65025605,CDM,510,RC,10021,HCPCS,Outpatient,,,173,173,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,126.29,73,,101.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121.1,70,,96.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.2,19.19,,26.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.5,50,,69.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.2,1508.85,
Fine Needle Aspiration Biopsy without imaging,67010021,CDM,510,RC,10060,HCPCS,Outpatient,,,77,77,,,,,,Other,Not Separately Reimbursable,63.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,63.53,82.5,,50.824,percent of total billed charges,Pays at 82.5% of total Billed charges,56.21,73,,44.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.9,70,,43.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,19.19,,11.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,50,,30.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,63.53,
Incision and drainage of abscess; simple or single and complex or multiple,67010060,CDM,510,RC,10061,HCPCS,Outpatient,,,106,106,,,,,,Other,Not Separately Reimbursable,87.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,87.45,82.5,,69.96,percent of total billed charges,Pays at 82.5% of total Billed charges,77.38,73,,61.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.2,70,,59.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.34,19.19,,16.272,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53,50,,42.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.34,87.45,
I&D ABSCESS COMPLEX,67010061,CDM,510,RC,10080,HCPCS,Outpatient,,,197,197,,,,,,Other,Not Separately Reimbursable,162.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,162.53,82.5,,130.024,percent of total billed charges,Pays at 82.5% of total Billed charges,143.81,73,,115.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.9,70,,110.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,19.19,,30.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.5,50,,78.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,162.53,
I&D CYST SIMPLE,67010080,CDM,510,RC,10081,HCPCS,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,93.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,93.23,82.5,,74.584,percent of total billed charges,Pays at 82.5% of total Billed charges,82.49,73,,65.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.1,70,,63.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,19.19,,17.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.5,50,,45.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,93.23,
I&D CYST COMPLEX,67010081,CDM,510,RC,10120,HCPCS,Outpatient,,,188,188,,,,,,Other,Not Separately Reimbursable,155.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,155.1,82.5,,124.08,percent of total billed charges,Pays at 82.5% of total Billed charges,137.24,73,,109.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,131.6,70,,105.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.08,19.19,,28.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94,50,,75.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.08,155.1,
I&D RMV FB SIMPLE,67010120,CDM,510,RC,10121,HCPCS,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,93.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,93.23,82.5,,74.584,percent of total billed charges,Pays at 82.5% of total Billed charges,82.49,73,,65.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.1,70,,63.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,19.19,,17.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.5,50,,45.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,93.23,
I&D RMV FB COMPLEX,67010121,CDM,510,RC,10140,HCPCS,Outpatient,,,205,205,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,149.65,73,,119.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.5,70,,114.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,19.19,,31.472,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.5,50,,82,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,1319.85,
"Incision and drainage of hematoma, seroma or fluid collection",67010140,CDM,510,RC,10160,HCPCS,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",67010160,CDM,510,RC,10180,HCPCS,Outpatient,,,105,105,,,,,,Other,Not Separately Reimbursable,86.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,86.63,82.5,,69.304,percent of total billed charges,Pays at 82.5% of total Billed charges,76.65,73,,61.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.5,70,,58.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,19.19,,16.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,50,,42,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,86.63,
I&D POST-OP WOUND INFECTION,67010180,CDM,510,RC,11000,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,146,73,,116.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,70,,112,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,19.19,,30.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100,50,,80,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,1319.85,
Removal of infected skin,67011000,CDM,510,RC,11004,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
DEBRIDE GENITALS & PERINEUM,67011004,CDM,510,RC,11011,HCPCS,Outpatient,,,658,658,,,,,,Other,Not Separately Reimbursable,542.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,542.85,82.5,,434.28,percent of total billed charges,Pays at 82.5% of total Billed charges,480.34,73,,384.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,460.6,70,,368.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126.27,19.19,,101.016,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,329,50,,263.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126.27,542.85,
"DEBRIDE SKIN/MUSCLE, FX",67011011,CDM,510,RC,11042,HCPCS,Outpatient,,,341,341,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,248.93,73,,199.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,238.7,70,,190.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.44,19.19,,52.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.5,50,,136.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.44,1319.85,
DEBRIDE SKIN/TISSUE,67011042,CDM,510,RC,11043,HCPCS,Outpatient,,,69,69,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,50.37,73,,40.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.3,70,,38.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.24,19.19,,10.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,50,,27.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.24,1319.85,
DEBRIDE TISSUE/MUSCLE,67011043,CDM,510,RC,11044,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,127.02,73,,101.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121.8,70,,97.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.39,19.19,,26.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87,50,,69.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.39,1319.85,
DEBRIDE BONE FIRST 20 SQCM OR LESS,67011044,CDM,510,RC,11046,HCPCS,Outpatient,,,259,259,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,189.07,73,,151.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,181.3,70,,145.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,19.19,,39.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,129.5,50,,103.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,1319.85,
WND DEBRID(TISSUE& MUSCLE)EA ADDL 20SQCM,67011046,CDM,510,RC,11055,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
TRIM SKIN LESION SINGLE,67011055,CDM,510,RC,11200,HCPCS,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,14.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,14.85,82.5,,11.88,percent of total billed charges,Pays at 82.5% of total Billed charges,13.14,73,,10.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.6,70,,10.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,19.19,,2.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9,50,,7.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.45,14.85,
"Removal of skin tags, multiple fibrocutaneous tags, any area",67011200,CDM,510,RC,11201,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
RMV SKIN TAGS ADD-ON,67011201,CDM,510,RC,11400,HCPCS,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,15.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,15.68,82.5,,12.544,percent of total billed charges,Pays at 82.5% of total Billed charges,13.87,73,,11.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.3,70,,10.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,19.19,,2.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.5,50,,7.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,15.68,
EXC-BENIGN TRUNK/ARM/LEGS <0.5 CM,67011400,CDM,510,RC,11401,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,73.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,73.43,82.5,,58.744,percent of total billed charges,Pays at 82.5% of total Billed charges,64.97,73,,51.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.3,70,,49.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,19.19,,13.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.5,50,,35.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,73.43,
Under Excision-Benign Lesions Procedures on the Skin 0.6-1 CM,67011401,CDM,510,RC,11402,HCPCS,Outpatient,,,114,114,,,,,,Other,Not Separately Reimbursable,94.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,94.05,82.5,,75.24,percent of total billed charges,Pays at 82.5% of total Billed charges,83.22,73,,66.576,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.8,70,,63.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.88,19.19,,17.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57,50,,45.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.88,94.05,
EXC-BENIGN TRUNK/ARM/LEGS 1.1-2.0 CM,67011402,CDM,510,RC,11403,HCPCS,Outpatient,,,127,127,,,,,,Other,Not Separately Reimbursable,104.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,104.78,82.5,,83.824,percent of total billed charges,Pays at 82.5% of total Billed charges,92.71,73,,74.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.9,70,,71.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.37,19.19,,19.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.5,50,,50.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.37,104.78,
EXC-BENIGN TRUNK/ARM/LEGS 2.1-3.0 CM,67011403,CDM,510,RC,11404,HCPCS,Outpatient,,,163,163,,,,,,Other,Not Separately Reimbursable,134.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,134.48,82.5,,107.584,percent of total billed charges,Pays at 82.5% of total Billed charges,118.99,73,,95.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,114.1,70,,91.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.28,19.19,,25.024,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.5,50,,65.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.28,134.48,
EXC-BENIGN TRUNK/ARM/LEGS 3.1-4.0 CM,67011404,CDM,510,RC,11406,HCPCS,Outpatient,,,180,180,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,131.4,73,,105.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126,70,,100.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,19.19,,27.632,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90,50,,72,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.54,982.8,
EXCIS BENIGN LES TRUNK/ARM/LEGS>4.0CM,67011406,CDM,510,RC,11420,HCPCS,Outpatient,,,278,278,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,202.94,73,,162.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,194.6,70,,155.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.35,19.19,,42.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139,50,,111.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.35,1319.85,
EXC-BENIGN SP/NK/H/F/G <0.5 CM,67011420,CDM,510,RC,11421,HCPCS,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,74.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,74.25,82.5,,59.4,percent of total billed charges,Pays at 82.5% of total Billed charges,65.7,73,,52.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,70,,50.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,19.19,,13.816,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45,50,,36,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.27,74.25,
EXC-BENIGN SP/NK/H/F/G 0.6-1.0 CM,67011421,CDM,510,RC,11422,HCPCS,Outpatient,,,121,121,,,,,,Other,Not Separately Reimbursable,99.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99.83,82.5,,79.864,percent of total billed charges,Pays at 82.5% of total Billed charges,88.33,73,,70.664,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.7,70,,67.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.22,19.19,,18.576,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.5,50,,48.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.22,99.83,
Under Excision-Benign Lesions Procedures on the Skin 1.1-2 CM,67011422,CDM,510,RC,11423,HCPCS,Outpatient,,,151,151,,,,,,Other,Not Separately Reimbursable,124.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,124.58,82.5,,99.664,percent of total billed charges,Pays at 82.5% of total Billed charges,110.23,73,,88.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.7,70,,84.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.98,19.19,,23.184,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75.5,50,,60.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.98,124.58,
EXC-BENIGN SP/NK/H/F/G 2.1-3.0 CM,67011423,CDM,510,RC,11424,HCPCS,Outpatient,,,173,173,,,,,,Other,Not Separately Reimbursable,142.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,142.73,82.5,,114.184,percent of total billed charges,Pays at 82.5% of total Billed charges,126.29,73,,101.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121.1,70,,96.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.2,19.19,,26.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.5,50,,69.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.2,142.73,
EXC-BENIGN SP/NK/H/F/G 3.1-4.0 CM,67011424,CDM,510,RC,11426,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,146,73,,116.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,70,,112,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,19.19,,30.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100,50,,80,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,1319.85,
EXCISION OF BENIGN LESION>4CM,67011426,CDM,510,RC,11440,HCPCS,Outpatient,,,309,309,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,225.57,73,,180.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216.3,70,,173.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.3,19.19,,47.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154.5,50,,123.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.3,1319.85,
EXC-BENIGN FACE/EARS/ETC .5CM OR <,67011440,CDM,510,RC,11441,HCPCS,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,93.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,93.23,82.5,,74.584,percent of total billed charges,Pays at 82.5% of total Billed charges,82.49,73,,65.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.1,70,,63.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,19.19,,17.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.5,50,,45.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,93.23,
EXC-BENIGN FACE/EARS/ETC 0.6-1.0 CM,67011441,CDM,510,RC,11442,HCPCS,Outpatient,,,144,144,,,,,,Other,Not Separately Reimbursable,118.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,118.8,82.5,,95.04,percent of total billed charges,Pays at 82.5% of total Billed charges,105.12,73,,84.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.8,70,,80.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.63,19.19,,22.104,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72,50,,57.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.63,118.8,
EXC-BENIGN FACE/EARS/ETC 1.1-2.0 CM,67011442,CDM,510,RC,11443,HCPCS,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
EXC-BENIGN FACE/EARS/ETC 2.1-3.0 CM,67011443,CDM,510,RC,11444,HCPCS,Outpatient,,,197,197,,,,,,Other,Not Separately Reimbursable,162.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,162.53,82.5,,130.024,percent of total billed charges,Pays at 82.5% of total Billed charges,143.81,73,,115.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.9,70,,110.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,19.19,,30.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.5,50,,78.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,162.53,
EXC-BENIGN FACE/EARS/ETC 3.1-4.0 CM,67011444,CDM,510,RC,11451,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,183.96,73,,147.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.4,70,,141.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.36,19.19,,38.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126,50,,100.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.36,982.8,
HIDRADENITIS EXCISION W/COMPLEX REPAIR,67011451,CDM,510,RC,11600,HCPCS,Outpatient,,,364,364,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,265.72,73,,212.576,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,254.8,70,,203.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.85,19.19,,55.88,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182,50,,145.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.85,1319.85,
EXC-MALIG TRUNK/ARMS/LEGS <0.5 CM,67011600,CDM,510,RC,11601,HCPCS,Outpatient,,,132,132,,,,,,Other,Not Separately Reimbursable,108.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,108.9,82.5,,87.12,percent of total billed charges,Pays at 82.5% of total Billed charges,96.36,73,,77.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.4,70,,73.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.33,19.19,,20.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66,50,,52.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.33,108.9,
EXC-MALIG TRUNK/ARMS/LEGS 0.6 -1.0 CM,67011601,CDM,510,RC,11602,HCPCS,Outpatient,,,165,165,,,,,,Other,Not Separately Reimbursable,136.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,136.13,82.5,,108.904,percent of total billed charges,Pays at 82.5% of total Billed charges,120.45,73,,96.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.5,70,,92.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.66,19.19,,25.328,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.5,50,,66,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.66,136.13,
Excision-Malignant Lesions,67011602,CDM,510,RC,11603,HCPCS,Outpatient,,,182,182,,,,,,Other,Not Separately Reimbursable,150.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,150.15,82.5,,120.12,percent of total billed charges,Pays at 82.5% of total Billed charges,132.86,73,,106.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,127.4,70,,101.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.93,19.19,,27.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,50,,72.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.93,150.15,
EXC-MALIG TRUNK/ARMS/LEGS 2.1-3.0 CM,67011603,CDM,510,RC,11604,HCPCS,Outpatient,,,218,218,,,,,,Other,Not Separately Reimbursable,179.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,179.85,82.5,,143.88,percent of total billed charges,Pays at 82.5% of total Billed charges,159.14,73,,127.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,152.6,70,,122.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.83,19.19,,33.464,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109,50,,87.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.83,179.85,
EXC-MALIG TRUNK/ARMS/LEGS 3.1-4.0 CM,67011604,CDM,510,RC,11606,HCPCS,Outpatient,,,241,241,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,175.93,73,,140.744,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,168.7,70,,134.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.25,19.19,,37,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,120.5,50,,96.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.25,1319.85,
EXCISION OF MALIGNANT LESION>4CM,67011606,CDM,510,RC,11620,HCPCS,Outpatient,,,361,361,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,263.53,73,,210.824,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.7,70,,202.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.28,19.19,,55.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.5,50,,144.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.28,1319.85,
EXC-MALIG SP/NK/H/F/G <0.5 CM,67011620,CDM,510,RC,11621,HCPCS,Outpatient,,,134,134,,,,,,Other,Not Separately Reimbursable,110.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,110.55,82.5,,88.44,percent of total billed charges,Pays at 82.5% of total Billed charges,97.82,73,,78.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.8,70,,75.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.71,19.19,,20.568,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67,50,,53.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.71,110.55,
EXC-MALIG SP/NK/H/F/G 0.6-1.0 CM,67011621,CDM,510,RC,11622,HCPCS,Outpatient,,,166,166,,,,,,Other,Not Separately Reimbursable,136.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,136.95,82.5,,109.56,percent of total billed charges,Pays at 82.5% of total Billed charges,121.18,73,,96.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.2,70,,92.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.86,19.19,,25.488,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83,50,,66.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.86,136.95,
EXC-MALIG SP/NK/H/F/G 1.1-2.0 CM,67011622,CDM,510,RC,11623,HCPCS,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
EXC-MALIG SP/NK/H/F/G 2.1-3.0 CM,67011623,CDM,510,RC,11624,HCPCS,Outpatient,,,237,237,,,,,,Other,Not Separately Reimbursable,195.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,195.53,82.5,,156.424,percent of total billed charges,Pays at 82.5% of total Billed charges,173.01,73,,138.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165.9,70,,132.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.48,19.19,,36.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,118.5,50,,94.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.48,195.53,
EXC-MALIG SP/NK/H/F/G 3.1-4.0 CM,67011624,CDM,510,RC,11640,HCPCS,Outpatient,,,269,269,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,196.37,73,,157.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,188.3,70,,150.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.62,19.19,,41.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,134.5,50,,107.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.62,1319.85,
EXC-MALIG FACE/EARS/ETC <0.5CM,67011640,CDM,510,RC,11641,HCPCS,Outpatient,,,139,139,,,,,,Other,Not Separately Reimbursable,114.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,114.68,82.5,,91.744,percent of total billed charges,Pays at 82.5% of total Billed charges,101.47,73,,81.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.3,70,,77.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.67,19.19,,21.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.5,50,,55.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.67,114.68,
EXC-MALIG FACE/EARS/ETC 0.6-1.0 CM,67011641,CDM,510,RC,11642,HCPCS,Outpatient,,,173,173,,,,,,Other,Not Separately Reimbursable,142.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,142.73,82.5,,114.184,percent of total billed charges,Pays at 82.5% of total Billed charges,126.29,73,,101.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121.1,70,,96.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.2,19.19,,26.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.5,50,,69.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.2,142.73,
EXC-MALIG FACE/EARS/ETC 1.1-2.0 CM,67011642,CDM,510,RC,11643,HCPCS,Outpatient,,,204,204,,,,,,Other,Not Separately Reimbursable,168.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,168.3,82.5,,134.64,percent of total billed charges,Pays at 82.5% of total Billed charges,148.92,73,,119.136,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,142.8,70,,114.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.15,19.19,,31.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102,50,,81.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.15,168.3,
EXC-MALIG FACE/EARS/ETC 2.1-3.0 CM,67011643,CDM,510,RC,11644,HCPCS,Outpatient,,,257,257,,,,,,Other,Not Separately Reimbursable,212.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,212.03,82.5,,169.624,percent of total billed charges,Pays at 82.5% of total Billed charges,187.61,73,,150.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,179.9,70,,143.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.32,19.19,,39.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.5,50,,102.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.32,212.03,
EXC-MALIG FACE/EARS/ETC 3.1-4.0 CM,67011644,CDM,510,RC,11730,HCPCS,Outpatient,,,319,319,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,232.87,73,,186.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,223.3,70,,178.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.22,19.19,,48.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,159.5,50,,127.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.22,1319.85,
Separation and removal of the entire nail plate or a portion of nail plate,67011730,CDM,510,RC,11732,HCPCS,Outpatient,,,61,61,,,,,,Other,Not Separately Reimbursable,50.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,50.33,82.5,,40.264,percent of total billed charges,Pays at 82.5% of total Billed charges,44.53,73,,35.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.7,70,,34.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,19.19,,9.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.5,50,,24.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,50.33,
"RMV NAIL PLATE, ADD-ON",67011732,CDM,510,RC,11770,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
PILONIDAL CYST EXCISION SIMPLE,67011770,CDM,510,RC,11771,HCPCS,Outpatient,,,208,208,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,151.84,73,,121.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,145.6,70,,116.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.92,19.19,,31.936,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104,50,,83.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.92,1508.85,
PILONIDAL CYST EXCISION ESTENSIVE,67011771,CDM,510,RC,11772,HCPCS,Outpatient,,,491,491,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,358.43,73,,286.744,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,343.7,70,,274.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.22,19.19,,75.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245.5,50,,196.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.22,1508.85,
PILONIDAL CYST EXCISION COMPLICATED,67011772,CDM,510,RC,11901,HCPCS,Outpatient,,,645,645,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,470.85,73,,376.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,451.5,70,,361.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,123.78,19.19,,99.024,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,322.5,50,,258,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,123.78,1508.85,
"TRMT OF LESION, INJECTION, > 7 INJECTION",67011901,CDM,510,RC,11976,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
"REMOVAL,IMPLANTABLE CONTRACEPTIVE CAPSUL",67011976,CDM,510,RC,12001,HCPCS,Outpatient,,,104,104,,,,,,Other,Not Separately Reimbursable,85.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,85.8,82.5,,68.64,percent of total billed charges,Pays at 82.5% of total Billed charges,75.92,73,,60.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,72.8,70,,58.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.96,19.19,,15.968,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52,50,,41.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.96,85.8,
"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",67012001,CDM,510,RC,12002,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,41.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,41.25,82.5,,33,percent of total billed charges,Pays at 82.5% of total Billed charges,36.5,73,,29.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35,70,,28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,19.19,,7.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25,50,,20,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.6,41.25,
REPAIR OF SUPERFICIAL WOUND 2.6-7.5CM,67012002,CDM,510,RC,12004,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,54.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,54.45,82.5,,43.56,percent of total billed charges,Pays at 82.5% of total Billed charges,48.18,73,,38.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.2,70,,36.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,19.19,,10.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33,50,,26.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,54.45,
REPAIR SUPERFICIAL WOUND BODY 7.6-12.5CM,67012004,CDM,510,RC,12020,HCPCS,Outpatient,,,82,82,,,,,,Other,Not Separately Reimbursable,67.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,67.65,82.5,,54.12,percent of total billed charges,Pays at 82.5% of total Billed charges,59.86,73,,47.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.4,70,,45.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,19.19,,12.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41,50,,32.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,67.65,
TX SUPERFICIAL WOUND DEHISCENCE SIMPLE,67012020,CDM,510,RC,12031,HCPCS,Outpatient,,,209,209,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,152.57,73,,122.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,146.3,70,,117.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.11,19.19,,32.088,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.5,50,,83.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.11,982.8,
INTMD WD REPAIR S/TR/EXT 2.5CM OR LESS,67012031,CDM,510,RC,12032,HCPCS,Outpatient,,,170,170,,,,,,Other,Not Separately Reimbursable,140.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,140.25,82.5,,112.2,percent of total billed charges,Pays at 82.5% of total Billed charges,124.1,73,,99.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,119,70,,95.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.62,19.19,,26.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85,50,,68,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.62,140.25,
INTMD WD REPAIR S/TR/EXT 2.6-7.5 CM,67012032,CDM,510,RC,12034,HCPCS,Outpatient,,,216,216,,,,,,Other,Not Separately Reimbursable,178.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,178.2,82.5,,142.56,percent of total billed charges,Pays at 82.5% of total Billed charges,157.68,73,,126.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.2,70,,120.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.45,19.19,,33.16,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108,50,,86.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.45,178.2,
INTMD WD REPAIR S/TR/EXT 7.6-12.5CM,67012034,CDM,510,RC,12036,HCPCS,Outpatient,,,232,232,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,169.36,73,,135.488,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,162.4,70,,129.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.52,19.19,,35.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116,50,,92.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.52,1319.85,
INTER WOUND REPAIR/BODY 20.1-30.0CM,67012036,CDM,510,RC,12042,HCPCS,Outpatient,,,315,315,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,229.95,73,,183.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,220.5,70,,176.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.45,19.19,,48.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.5,50,,126,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.45,1319.85,
REP INTER WOUND NK 2.6 - 7.5 CM,67012042,CDM,510,RC,12045,HCPCS,Outpatient,,,223,223,,,,,,Other,Not Separately Reimbursable,183.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,183.98,82.5,,147.184,percent of total billed charges,Pays at 82.5% of total Billed charges,162.79,73,,130.232,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,156.1,70,,124.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.79,19.19,,34.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.5,50,,89.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.79,183.98,
INTERMEDIATE REPAIR 12.6-20.0 CM,67012045,CDM,510,RC,12046,HCPCS,Outpatient,,,300,300,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,219,73,,175.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,210,70,,168,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.57,19.19,,46.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,150,50,,120,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.57,1319.85,
INTERMEDIATE REPAIR 20.1-30.3,67012046,CDM,510,RC,12051,HCPCS,Outpatient,,,352,352,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,256.96,73,,205.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,246.4,70,,197.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.55,19.19,,54.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176,50,,140.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.55,1319.85,
INTMD WD REPAIR F/E/EY/N/L/MM 2.5CM OR >,67012051,CDM,510,RC,12052,HCPCS,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,156.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,156.75,82.5,,125.4,percent of total billed charges,Pays at 82.5% of total Billed charges,138.7,73,,110.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133,70,,106.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,19.19,,29.168,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95,50,,76,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.46,156.75,
INTERMEDIATE WOUND REPAIR/FACE 2.6-5.0CM,67012052,CDM,510,RC,13131,HCPCS,Outpatient,,,227,227,,,,,,Other,Not Separately Reimbursable,187.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,187.28,82.5,,149.824,percent of total billed charges,Pays at 82.5% of total Billed charges,165.71,73,,132.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,158.9,70,,127.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.56,19.19,,34.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,113.5,50,,90.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.56,187.28,
REPAIR OF WOUND OR LESION,67013131,CDM,510,RC,13132,HCPCS,Outpatient,,,279,279,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,203.67,73,,162.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,195.3,70,,156.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.54,19.19,,42.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,139.5,50,,111.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.54,1319.85,
"REPAIR,COMPLEX 2.6CM-7.5CM",67013132,CDM,510,RC,14302,HCPCS,Outpatient,,,352,352,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,256.96,73,,205.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,246.4,70,,197.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.55,19.19,,54.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176,50,,140.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.55,1508.85,
ADJACENT TISSUE TRSFR EA ADDL 30 SQ CM,67014302,CDM,510,RC,15101,HCPCS,Outpatient,,,250,250,,,,,,Other,Not Separately Reimbursable,1861.65,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1861.65,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,182.5,73,,146,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,70,,140,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,19.19,,38.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125,50,,100,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,1861.65,
"SKIN SPLT GRFT T/A/L, ADD-ON",67015101,CDM,510,RC,15120,HCPCS,Outpatient,,,125,125,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,91.25,73,,73,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,70,,70,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,19.19,,19.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.5,50,,50,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,1508.85,
SKIN SPLT A-GRFT FAC/NCK/HF/G,67015120,CDM,510,RC,15121,HCPCS,Outpatient,,,777,777,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,567.21,73,,453.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,543.9,70,,435.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.11,19.19,,119.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,388.5,50,,310.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.11,1319.85,
SKIN SPLT A-GRFT F/N/HG/G ADD-ON,67015121,CDM,510,RC,15271,HCPCS,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,109.5,73,,87.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,70,,84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,19.19,,23.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75,50,,60,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,1508.85,
APPL OF SKIN SUBS GRFT UP TO 100CM,67015271,CDM,510,RC,15275,HCPCS,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,1319.85,
APPL SKIN SUB GRAFT F/S/EL/M/N/E/O/G/H/F,67015275,CDM,510,RC,15931,HCPCS,Outpatient,,,106,106,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,77.38,73,,61.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.2,70,,59.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.34,19.19,,16.272,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53,50,,42.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.34,1319.85,
"EXC, SACRAL PRESSURE ULCER, W/PRIM SUTUR",67015931,CDM,510,RC,16020,HCPCS,Outpatient,,,777,777,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,567.21,73,,453.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,543.9,70,,435.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.11,19.19,,119.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,388.5,50,,310.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149.11,1508.85,
SKIN BURNSDRESS/DEBRID P-THICK S,67016020,CDM,510,RC,16025,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
SKIN BURNSDRESS/DEBRID P-THICK M,67016025,CDM,510,RC,16030,HCPCS,Outpatient,,,124,124,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,90.52,73,,72.416,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.8,70,,69.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,19.19,,19.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62,50,,49.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.8,1319.85,
SKIN BURNSDRESS/DEBRID P-THICK L,67016030,CDM,510,RC,17110,HCPCS,Outpatient,,,151,151,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,110.23,73,,88.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.7,70,,84.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.98,19.19,,23.184,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75.5,50,,60.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.98,982.8,
Destruction of 1-14 common or plantar warts,67017110,CDM,510,RC,17250,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,54.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,54.45,82.5,,43.56,percent of total billed charges,Pays at 82.5% of total Billed charges,48.18,73,,38.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.2,70,,36.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,19.19,,10.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33,50,,26.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,54.45,
Chemical destruction of pre-cancerous lesions of the skin,67017250,CDM,510,RC,19000,HCPCS,Outpatient,,,41,41,,,,,,Other,Not Separately Reimbursable,33.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33.83,82.5,,27.064,percent of total billed charges,Pays at 82.5% of total Billed charges,29.93,73,,23.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.7,70,,22.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,19.19,,6.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.5,50,,16.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,33.83,
ASPIRATION OF BREAST CYST,67019000,CDM,510,RC,19001,HCPCS,Outpatient,,,49,49,,,,,,Other,Not Separately Reimbursable,40.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,40.43,82.5,,32.344,percent of total billed charges,Pays at 82.5% of total Billed charges,35.77,73,,28.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.3,70,,27.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,19.19,,7.52,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,50,,19.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.4,40.43,
ASPIRATION OF BREAST CYST ADD-ON,67019001,CDM,510,RC,19020,HCPCS,Outpatient,,,24,24,,,,,,Other,Not Separately Reimbursable,19.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,19.8,82.5,,15.84,percent of total billed charges,Pays at 82.5% of total Billed charges,17.52,73,,14.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.8,70,,13.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.61,19.19,,3.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12,50,,9.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.61,19.8,
I&D BREAST ABSCESS,67019020,CDM,510,RC,19100,HCPCS,Outpatient,,,344,344,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,251.12,73,,200.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,240.8,70,,192.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.01,19.19,,52.808,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,172,50,,137.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.01,1319.85,
BREAST BIOPSY NEEDLE,67019100,CDM,510,RC,19101,HCPCS,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,982.8,
BREAST BIOPSY OPEN,67019101,CDM,510,RC,19120,HCPCS,Outpatient,,,250,250,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,182.5,73,,146,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,175,70,,140,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,19.19,,38.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,125,50,,100,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.98,1319.85,
REMOVAL OF BREAST LESION,67019120,CDM,510,RC,19300,HCPCS,Outpatient,,,468,468,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,341.64,73,,273.312,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,327.6,70,,262.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.81,19.19,,71.848,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,234,50,,187.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.81,1508.85,
REMOVAL OF BREAST TISSUE,67019300,CDM,510,RC,19302,HCPCS,Outpatient,,,465,465,,,,,,Other,Not Separately Reimbursable,1861.65,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1861.65,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,339.45,73,,271.56,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,325.5,70,,260.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.23,19.19,,71.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,232.5,50,,186,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,89.23,1861.65,
PARTIAL MASTECTOMY W/LN REMOVAL,67019302,CDM,510,RC,20102,HCPCS,Outpatient,,,244,244,,,,,,Other,Not Separately Reimbursable,2945.25,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,2945.25,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,178.12,73,,142.496,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.8,70,,136.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.82,19.19,,37.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122,50,,97.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.82,2945.25,
"EXPLORE WOUND, ABDOMEN",67020102,CDM,510,RC,20206,HCPCS,Outpatient,,,291,291,,,,,,Other,Not Separately Reimbursable,240.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,240.08,82.5,,192.064,percent of total billed charges,Pays at 82.5% of total Billed charges,212.43,73,,169.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203.7,70,,162.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.84,19.19,,44.672,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,145.5,50,,116.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.84,240.08,
BIOPSY MUSCLE PERCUTANEOUS NEEDLE,67020206,CDM,510,RC,20250,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,982.8,
"BIOPSY, VERTEBRAL BODY, OPEN;THORACIC",67020250,CDM,510,RC,20525,HCPCS,Outpatient,,,441,441,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,321.93,73,,257.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,308.7,70,,246.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.63,19.19,,67.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,220.5,50,,176.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84.63,1508.85,
REM OF FOR BODY MUSC/TEND SHEATH;COMPLIC,67020525,CDM,510,RC,20605,HCPCS,Outpatient,,,276,276,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,201.48,73,,161.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,193.2,70,,154.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.96,19.19,,42.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,138,50,,110.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.96,1508.85,
Draining or injecting medication into a large joint/bursa without ultrasound,67020605,CDM,510,RC,21555,HCPCS,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
RMV TUMOR NECK/THORAX SUBCUT <3 CM,67021555,CDM,510,RC,21920,HCPCS,Outpatient,,,341,341,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,248.93,73,,199.144,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,238.7,70,,190.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.44,19.19,,52.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.5,50,,136.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.44,1319.85,
BIOPSY BACK/FLANK SUPERFICIAL,67021920,CDM,510,RC,21925,HCPCS,Outpatient,,,177,177,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,129.21,73,,103.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,123.9,70,,99.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.97,19.19,,27.176,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.5,50,,70.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.97,982.8,
BIOPSY BACK/FLANK DEEP,67021925,CDM,510,RC,21930,HCPCS,Outpatient,,,398,398,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,290.54,73,,232.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,278.6,70,,222.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.38,19.19,,61.104,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,199,50,,159.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.38,1319.85,
RMV TUMOR BACK/FLANK,67021930,CDM,510,RC,21932,HCPCS,Outpatient,,,410,410,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,299.3,73,,239.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,287,70,,229.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,19.19,,62.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205,50,,164,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.68,1319.85,
EXCISION TUMOR SOFT TISSUE BACK <5CM,67021932,CDM,510,RC,23075,HCPCS,Outpatient,,,750,750,,,,,,Other,Not Separately Reimbursable,618.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,618.75,82.5,,495,percent of total billed charges,Pays at 82.5% of total Billed charges,547.5,73,,438,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,525,70,,420,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.93,19.19,,115.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,375,50,,300,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.93,618.75,
RMV TUMOR SHOULDER SUBCUTANEOUS,67023075,CDM,510,RC,26010,HCPCS,Outpatient,,,367,367,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,267.91,73,,214.328,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,256.9,70,,205.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.43,19.19,,56.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,183.5,50,,146.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.43,1319.85,
FINGER ABCESS SIMPLE,67026010,CDM,510,RC,26011,HCPCS,Outpatient,,,151,151,,,,,,Other,Not Separately Reimbursable,124.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,124.58,82.5,,99.664,percent of total billed charges,Pays at 82.5% of total Billed charges,110.23,73,,88.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.7,70,,84.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.98,19.19,,23.184,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75.5,50,,60.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.98,124.58,
FINGER ABCESS COMPLEX,67026011,CDM,510,RC,27047,HCPCS,Outpatient,,,205,205,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,149.65,73,,119.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.5,70,,114.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,19.19,,31.472,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.5,50,,82,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,982.8,
RMV TUMOR PELVIS/HIP SUPERFICIAL,67027047,CDM,510,RC,81002,HCPCS,Outpatient,,,406,406,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,296.38,73,,237.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,284.2,70,,227.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.91,19.19,,62.328,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,203,50,,162.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.91,1319.85,
Manual urinalysis test with examination without using microscope,67036415,CDM,510,RC,36556,HCPCS,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,11.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,11.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,11.43,
CENTRAL LINE > 5 YEARS,67036556,CDM,510,RC,36558,HCPCS,Outpatient,,,109,109,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,79.57,73,,63.656,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.3,70,,61.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.92,19.19,,16.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.5,50,,43.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.92,982.8,
TUNNELED CENT. LINE > 5 YRS,67036558,CDM,510,RC,36569,HCPCS,Outpatient,,,294,294,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,214.62,73,,171.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,205.8,70,,164.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.42,19.19,,45.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,50,,117.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.42,1319.85,
INSERT OF PICC LINE W/O SUBC PORT;5OR>,67036569,CDM,510,RC,36582,HCPCS,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,69.35,73,,55.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,70,,53.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,19.19,,14.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.5,50,,38,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.23,982.8,
"REPLACE,COMPLETE, TUNNELED CENTR INSERTE",67036582,CDM,510,RC,36589,HCPCS,Outpatient,,,328,328,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,239.44,73,,191.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,229.6,70,,183.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.94,19.19,,50.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,164,50,,131.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.94,1508.85,
REMOVAL TUNNELED CATHETER,67036589,CDM,510,RC,36590,HCPCS,Outpatient,,,153,153,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,111.69,73,,89.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,107.1,70,,85.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.36,19.19,,23.488,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.5,50,,61.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.36,982.8,
PROTACATH REMOVAL,67036590,CDM,510,RC,38500,HCPCS,Outpatient,,,217,217,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,158.41,73,,126.728,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.9,70,,121.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.64,19.19,,33.312,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,108.5,50,,86.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.64,982.8,
"BIOPSY OR EXC OF LYMPH NODES;OPEN,SUPERF",67038500,CDM,510,RC,43255,HCPCS,Outpatient,,,289,289,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,210.97,73,,168.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,202.3,70,,161.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.46,19.19,,44.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.5,50,,115.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.46,1319.85,
"EGD W/CONTROL OF BLEEDING, ANY METHOD",67043255,CDM,510,RC,43762,HCPCS,Outpatient,,,229,229,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,167.17,73,,133.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,160.3,70,,128.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.95,19.19,,35.16,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,114.5,50,,91.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.95,1319.85,
REPLACEMENT OF GASTRO TUBE W/O IMAGING,67043762,CDM,510,RC,44205,HCPCS,Outpatient,,,44,44,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,32.12,73,,25.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.8,70,,24.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,19.19,,6.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22,50,,17.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,982.8,
"LAPAR,COLECTOMY, PARTIAL W/REM TERM ILIE",67044205,CDM,510,RC,45320,HCPCS,Outpatient,,,1142,1142,,,,,,Other,Not Separately Reimbursable,942.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,942.15,82.5,,753.72,percent of total billed charges,Pays at 82.5% of total Billed charges,833.66,73,,666.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,799.4,70,,639.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,219.15,19.19,,175.32,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,571,50,,456.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,219.15,942.15,
PROCTOSIGMOIDOSCOPY W/ABLATION,67045320,CDM,510,RC,45915,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,982.8,
REM OF FECAL IMPAC/FOREIGN BODY W/ANESTH,67045915,CDM,510,RC,46040,HCPCS,Outpatient,,,254,254,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,185.42,73,,148.336,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177.8,70,,142.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.74,19.19,,38.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,127,50,,101.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.74,982.8,
I&D ISCHIORECTAL/PERIRECTAL ABSCESS,67046040,CDM,510,RC,46045,HCPCS,Outpatient,,,474,474,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,346.02,73,,276.816,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,331.8,70,,265.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.96,19.19,,72.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,237,50,,189.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.96,1508.85,
I&D INTRAMURAL/INTRAMUS/SUBMUC ABSC W/AN,67046045,CDM,510,RC,46050,HCPCS,Outpatient,,,487,487,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,355.51,73,,284.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,340.9,70,,272.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.46,19.19,,74.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,243.5,50,,194.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.46,1319.85,
"I&D, PERIANAL ABSCESS, SUPERFICIAL",67046050,CDM,510,RC,46083,HCPCS,Outpatient,,,109,109,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,79.57,73,,63.656,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.3,70,,61.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.92,19.19,,16.736,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.5,50,,43.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.92,982.8,
INCISION THROMBOSED HEMORRHOID EXT,67046083,CDM,510,RC,46221,HCPCS,Outpatient,,,119,119,,,,,,Other,Not Separately Reimbursable,98.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,98.18,82.5,,78.544,percent of total billed charges,Pays at 82.5% of total Billed charges,86.87,73,,69.496,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.3,70,,66.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.84,19.19,,18.272,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,50,,47.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.84,98.18,
HEMORRHOID BANDING,67046221,CDM,510,RC,46505,HCPCS,Outpatient,,,211,211,,,,,,Other,Not Separately Reimbursable,174.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,174.08,82.5,,139.264,percent of total billed charges,Pays at 82.5% of total Billed charges,154.03,73,,123.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147.7,70,,118.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.49,19.19,,32.392,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105.5,50,,84.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.49,174.08,
CHEMODENERVATION OF INTERNAL ANAL SPHINC,67046505,CDM,510,RC,46600,HCPCS,Outpatient,,,267,267,,,,,,Other,Not Separately Reimbursable,220.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,220.28,82.5,,176.224,percent of total billed charges,Pays at 82.5% of total Billed charges,194.91,73,,155.928,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.9,70,,149.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.24,19.19,,40.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,133.5,50,,106.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.24,220.28,
ANOSCOPY DIAGNOSTIC,67046600,CDM,510,RC,49083,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
ABDOMINAL PARACENTESIS W/IMAGING GUIDANC,67049083,CDM,510,RC,55060,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,1319.85,
REPAIR TUNICA VAGINALIS HYDROCELE,67055060,CDM,510,RC,55100,HCPCS,Outpatient,,,425,425,,,,,,Other,Not Separately Reimbursable,1861.65,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1861.65,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,310.25,73,,248.2,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,297.5,70,,238,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.56,19.19,,65.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,212.5,50,,170,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.56,1861.65,
DRAINAGE OF SCROTAL WALL ABCESS,67055100,CDM,510,RC,56405,HCPCS,Outpatient,,,185,185,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,135.05,73,,108.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,129.5,70,,103.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,19.19,,28.4,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92.5,50,,74,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,982.8,
I&D OF PERINEAL ABSCESS,67056405,CDM,510,RC,56420,HCPCS,Outpatient,,,118,118,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,86.14,73,,68.912,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.6,70,,66.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,19.19,,18.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59,50,,47.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.64,1319.85,
DRAINAGE OF GLAND ABSCESS,67056420,CDM,510,RC,69210,HCPCS,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,82.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,82.5,82.5,,66,percent of total billed charges,Pays at 82.5% of total Billed charges,73,73,,58.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,70,,56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,19.19,,15.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50,50,,40,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.19,82.5,
Removal of ear wax from one or both ears,67069210,CDM,510,RC,76937,HCPCS,Outpatient,,,36,36,,,,,,Other,Not Separately Reimbursable,29.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,29.7,82.5,,23.76,percent of total billed charges,Pays at 82.5% of total Billed charges,26.28,73,,21.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.2,70,,20.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,19.19,,5.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18,50,,14.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,29.7,
U/S GUIDE VASCULAR ACCESS REQ U/S EVAL P,67076937,CDM,510,RC,97597,HCPCS,Outpatient,,,37,37,,,,,,Other,Not Separately Reimbursable,30.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,30.53,82.5,,24.424,percent of total billed charges,Pays at 82.5% of total Billed charges,27.01,73,,21.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.9,70,,20.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,19.19,,5.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.5,50,,14.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,30.53,
"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",67097597,CDM,510,RC,97605,HCPCS,Outpatient,,,26,26,,,,,,Other,Not Separately Reimbursable,21.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,21.45,82.5,,17.16,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,73,,15.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.2,70,,14.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,19.19,,3.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13,50,,10.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,21.45,
NEG PRESS WOUND THERAPY < OR = 50 SQ CM,67097605,CDM,510,RC,97606,HCPCS,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,23.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.1,82.5,,18.48,percent of total billed charges,Pays at 82.5% of total Billed charges,20.44,73,,16.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.6,70,,15.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,19.19,,4.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,50,,11.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,23.1,
NEG PRESS WOUND THERAPY > 50 SQ CM,67097606,CDM,510,RC,99201,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
OFFICE VISIT 10 MIN NEW,67099201,CDM,510,RC,99202,HCPCS,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,23.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.93,82.5,,19.144,percent of total billed charges,Pays at 82.5% of total Billed charges,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,23.93,
"New patient office or other outpatient visit, typically 10 minutes",67099202,CDM,510,RC,99203,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
"New patient office or other outpatient visit, typically 30 min",67099203,CDM,510,RC,99204,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,69.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,69.3,82.5,,55.44,percent of total billed charges,Pays at 82.5% of total Billed charges,61.32,73,,49.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.8,70,,47.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,19.19,,12.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,50,,33.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,69.3,
"New patient office of other outpatient visit, typically 45 min",67099204,CDM,510,RC,99205,HCPCS,Outpatient,,,141,141,,,,,,Other,Not Separately Reimbursable,116.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,116.33,82.5,,93.064,percent of total billed charges,Pays at 82.5% of total Billed charges,102.93,73,,82.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.7,70,,78.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,19.19,,21.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.5,50,,56.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,116.33,
"New patient office of other outpatient visit, typically 60 min",67099205,CDM,510,RC,99211,HCPCS,Outpatient,,,184,184,,,,,,Other,Not Separately Reimbursable,151.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,151.8,82.5,,121.44,percent of total billed charges,Pays at 82.5% of total Billed charges,134.32,73,,107.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.8,70,,103.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,19.19,,28.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92,50,,73.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,151.8,
Outpatient visit of established patient not requiring a physician,67099211,CDM,510,RC,99212,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
Outpatient visit of established patient requiring a physician,67099212,CDM,510,RC,99213,HCPCS,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
"Established patient office or other outpatient visit, typically 15 minutes",67099213,CDM,510,RC,99214,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
"Established patient office or other outpatient visit, typically 25 minutes",67099214,CDM,510,RC,99215,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
"Established patient office or other outpatient, visit typically 40 minutes",67099215,CDM,510,RC,99201,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
OFFICE VISIT 10 MIN NEW,67199201,CDM,510,RC,99202,HCPCS,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,23.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.93,82.5,,19.144,percent of total billed charges,Pays at 82.5% of total Billed charges,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,23.93,
OFFICE VISIT 20 MIN NEW,67199202,CDM,510,RC,99203,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
OFFICE VISIT 30 MIN NEW,67199203,CDM,510,RC,99204,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,69.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,69.3,82.5,,55.44,percent of total billed charges,Pays at 82.5% of total Billed charges,61.32,73,,49.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.8,70,,47.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,19.19,,12.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,50,,33.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,69.3,
OFFICE VISIT 45 MIN NEW,67199204,CDM,510,RC,99205,HCPCS,Outpatient,,,141,141,,,,,,Other,Not Separately Reimbursable,116.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,116.33,82.5,,93.064,percent of total billed charges,Pays at 82.5% of total Billed charges,102.93,73,,82.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.7,70,,78.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,19.19,,21.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.5,50,,56.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,116.33,
OFFICE VISIT 60 MIN NEW,67199205,CDM,510,RC,99211,HCPCS,Outpatient,,,184,184,,,,,,Other,Not Separately Reimbursable,151.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,151.8,82.5,,121.44,percent of total billed charges,Pays at 82.5% of total Billed charges,134.32,73,,107.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.8,70,,103.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,19.19,,28.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92,50,,73.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,151.8,
OFFICE VISIT 5 MIN EST,67199211,CDM,510,RC,99212,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
OFFICE VISIT 10 MIN EST,67199212,CDM,510,RC,99213,HCPCS,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
OFFICE VISIT 15 MIN EST,67199213,CDM,510,RC,99214,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
OFFICE VISIT 25 MIN EST,67199214,CDM,510,RC,99215,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
OFFICE VISIT 40 MIN EST,67199215,CDM,510,RC,99201,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
OFFICE VISIT 10 MIN NEW,67299201,CDM,510,RC,99202,HCPCS,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,23.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.93,82.5,,19.144,percent of total billed charges,Pays at 82.5% of total Billed charges,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,23.93,
OFFICE VISIT 20 MIN NEW,67299202,CDM,510,RC,99203,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
OFFICE VISIT 30 MIN NEW,67299203,CDM,510,RC,99204,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,69.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,69.3,82.5,,55.44,percent of total billed charges,Pays at 82.5% of total Billed charges,61.32,73,,49.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.8,70,,47.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,19.19,,12.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,50,,33.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,69.3,
OFFICE VISIT 45 MIN NEW,67299204,CDM,510,RC,99205,HCPCS,Outpatient,,,141,141,,,,,,Other,Not Separately Reimbursable,116.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,116.33,82.5,,93.064,percent of total billed charges,Pays at 82.5% of total Billed charges,102.93,73,,82.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.7,70,,78.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,19.19,,21.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.5,50,,56.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,116.33,
OFFICE VISIT 60 MIN NEW,67299205,CDM,510,RC,99211,HCPCS,Outpatient,,,184,184,,,,,,Other,Not Separately Reimbursable,151.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,151.8,82.5,,121.44,percent of total billed charges,Pays at 82.5% of total Billed charges,134.32,73,,107.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.8,70,,103.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,19.19,,28.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92,50,,73.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,151.8,
OFFICE VISIT 5 MIN EST,67299211,CDM,510,RC,99212,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
OFFICE VISIT 10 MIN EST,67299212,CDM,510,RC,99213,HCPCS,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
OFFICE VISIT 15 MIN EST,67299213,CDM,510,RC,99214,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
OFFICE VISIT 25 MIN EST,67299214,CDM,510,RC,99215,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
OFFICE VISIT 40 MIN EST,67299215,CDM,510,RC,99200,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
OFFICE VISIT 10 MIN NEW,67399201,CDM,510,RC,99200,HCPCS,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,23.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.93,82.5,,19.144,percent of total billed charges,Pays at 82.5% of total Billed charges,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,23.93,
OFFICE VISIT 20 MIN NEW,67399202,CDM,510,RC,99200,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
OFFICE VISIT 30 MIN NEW,67399203,CDM,510,RC,99200,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,69.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,69.3,82.5,,55.44,percent of total billed charges,Pays at 82.5% of total Billed charges,61.32,73,,49.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.8,70,,47.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,19.19,,12.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,50,,33.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,69.3,
OFFICE VISIT 45 MIN NEW,67399204,CDM,510,RC,99200,HCPCS,Outpatient,,,141,141,,,,,,Other,Not Separately Reimbursable,116.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,116.33,82.5,,93.064,percent of total billed charges,Pays at 82.5% of total Billed charges,102.93,73,,82.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.7,70,,78.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,19.19,,21.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.5,50,,56.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,116.33,
OFFICE VISIT 60 MIN NEW,67399205,CDM,510,RC,99200,HCPCS,Outpatient,,,184,184,,,,,,Other,Not Separately Reimbursable,151.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,151.8,82.5,,121.44,percent of total billed charges,Pays at 82.5% of total Billed charges,134.32,73,,107.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.8,70,,103.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,19.19,,28.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92,50,,73.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,151.8,
OFFICE VISIT 5 MIN EST,67399211,CDM,510,RC,99200,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
OFFICE VISIT 10 MIN EST,67399212,CDM,510,RC,99200,HCPCS,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,11.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,11.55,82.5,,9.24,percent of total billed charges,Pays at 82.5% of total Billed charges,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,11.55,
OFFICE VISIT 15 MIN EST,67399213,CDM,510,RC,99200,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
OFFICE VISIT 25 MIN EST,67399214,CDM,510,RC,99200,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
OFFICE VISIT 40 MIN EST,67399215,CDM,510,RC,46050,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
I&D PERIANAL,67446050,CDM,510,RC,20605,HCPCS,Outpatient,,,170,170,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,124.1,73,,99.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,119,70,,95.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.62,19.19,,26.096,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85,50,,68,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.62,982.8,
Draining or injecting medication into a large joint/bursa without ultrasound,67920605,CDM,510,RC,20610,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
Draining or injecting medication into a major joint/bursa without ultrasound,67920610,CDM,510,RC,20612,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
Removal of fluid or injection of medication into a ganglion cyst,67920612,CDM,510,RC,G0463,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
PSYCHIATRIC HOSPITAL OP CLINIC VISIT,71000463,CDM,510,RC,90791,HCPCS,Outpatient,,,140,140,,,,,,Other,Not Separately Reimbursable,115.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,115.5,82.5,,92.4,percent of total billed charges,Pays at 82.5% of total Billed charges,102.2,73,,81.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98,70,,78.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,19.19,,21.496,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70,50,,56,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.87,115.5,
"A diagnostic tool employed by a psychiatrist to diagnose problems with memory, thought processes, and behaviors",71090791,CDM,900,RC,90792,HCPCS,Outpatient,,,295,295,,,,,,Other,Not Separately Reimbursable,243.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,243.38,82.5,,194.704,percent of total billed charges,Pays at 82.5% of total Billed charges,215.35,73,,172.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,206.5,70,,165.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.61,19.19,,45.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147.5,50,,118,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.61,243.38,
A diagnostic tool employed by a psychiatrist to determine if medications are needed,71090792,CDM,900,RC,90832,HCPCS,Outpatient,,,322,322,,,,,,Other,Not Separately Reimbursable,265.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,265.65,82.5,,212.52,percent of total billed charges,Pays at 82.5% of total Billed charges,235.06,73,,188.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,225.4,70,,180.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.79,19.19,,49.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,161,50,,128.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.79,265.65,
"Psychotherapy, 30 min",71090832,CDM,914,RC,90834,HCPCS,Outpatient,,,188,188,,,,,,Other,Not Separately Reimbursable,155.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,155.1,82.5,,124.08,percent of total billed charges,Pays at 82.5% of total Billed charges,137.24,73,,109.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,131.6,70,,105.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.08,19.19,,28.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.08,155.1,
"Psychotherapy, 45 min",71090834,CDM,914,RC,90837,HCPCS,Outpatient,,,225,225,,,,,,Other,Not Separately Reimbursable,185.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,185.63,82.5,,148.504,percent of total billed charges,Pays at 82.5% of total Billed charges,164.25,73,,131.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.5,70,,126,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,19.19,,34.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,185.63,
"Psychotherapy, 60 min",71090837,CDM,914,RC,90839,HCPCS,Outpatient,,,260,260,,,,,,Other,Not Separately Reimbursable,214.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,214.5,82.5,,171.6,percent of total billed charges,Pays at 82.5% of total Billed charges,189.8,73,,151.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182,70,,145.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,19.19,,39.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,214.5,
"Psychotherapy for crisis, first 60 minutes",71090839,CDM,914,RC,90840,HCPCS,Outpatient,,,345,345,,,,,,Other,Not Separately Reimbursable,284.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,284.63,82.5,,227.704,percent of total billed charges,Pays at 82.5% of total Billed charges,251.85,73,,201.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,241.5,70,,193.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.21,19.19,,52.968,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.21,284.63,
Psychotherapy for crisis,71090840,CDM,914,RC,90846,HCPCS,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,123.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,123.75,82.5,,99,percent of total billed charges,Pays at 82.5% of total Billed charges,109.5,73,,87.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,70,,84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,19.19,,23.032,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.79,123.75,
"Family psychotherapy, not including patient, 50 min",71090846,CDM,916,RC,90847,HCPCS,Outpatient,,,234,234,,,,,,Other,Not Separately Reimbursable,193.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,193.05,82.5,,154.44,percent of total billed charges,Pays at 82.5% of total Billed charges,170.82,73,,136.656,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.8,70,,131.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.9,19.19,,35.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.9,193.05,
"Family psychotherapy, including patient, 50 min",71090847,CDM,916,RC,90849,HCPCS,Outpatient,,,253,253,,,,,,Other,Not Separately Reimbursable,208.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,208.73,82.5,,166.984,percent of total billed charges,Pays at 82.5% of total Billed charges,184.69,73,,147.752,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177.1,70,,141.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.55,19.19,,38.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.55,208.73,
MULTIPLE-FAMILY GROUP PSYCHOTHERAPY,71090849,CDM,916,RC,90853,HCPCS,Outpatient,,,245,245,,,,,,Other,Not Separately Reimbursable,202.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,202.13,82.5,,161.704,percent of total billed charges,Pays at 82.5% of total Billed charges,178.85,73,,143.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,171.5,70,,137.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.02,19.19,,37.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.02,202.13,
Group psychotherapy,71090853,CDM,915,RC,90832,HCPCS,Outpatient,,,225,225,,,,,,Other,Not Separately Reimbursable,185.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,185.63,82.5,,148.504,percent of total billed charges,Pays at 82.5% of total Billed charges,164.25,73,,131.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.5,70,,126,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,19.19,,34.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,185.63,
INDIIVIDUAL PSYCHOTHERAPY 30MIN (59 MOD),71190832,CDM,914,RC,90834,HCPCS,Outpatient,,,188,188,,,,,,Other,Not Separately Reimbursable,155.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,155.1,82.5,,124.08,percent of total billed charges,Pays at 82.5% of total Billed charges,137.24,73,,109.792,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,131.6,70,,105.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.08,19.19,,28.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.08,155.1,
"INDIVIDUAL PSYCHOTHERAPY, 45MIN (59 MOD)",71190834,CDM,914,RC,90837,HCPCS,Outpatient,,,225,225,,,,,,Other,Not Separately Reimbursable,185.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,185.63,82.5,,148.504,percent of total billed charges,Pays at 82.5% of total Billed charges,164.25,73,,131.4,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.5,70,,126,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,19.19,,34.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.18,185.63,
"INDIVIDUAL PSYCHOTHERAPY, 60MIN (59 MOD)",71190837,CDM,914,RC,90847,HCPCS,Outpatient,,,260,260,,,,,,Other,Not Separately Reimbursable,214.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,214.5,82.5,,171.6,percent of total billed charges,Pays at 82.5% of total Billed charges,189.8,73,,151.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,182,70,,145.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,19.19,,39.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.89,214.5,
"Family psychotherapy, including patient, 50 min",71190847,CDM,916,RC,95805,HCPCS,Outpatient,,,328,328,,,,,,Other,Not Separately Reimbursable,270.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,270.6,82.5,,216.48,percent of total billed charges,Pays at 82.5% of total Billed charges,239.44,73,,191.552,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,229.6,70,,183.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.94,19.19,,50.352,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.94,270.6,
MULTIPLE SLEEP LATENCY TEST,74095805,CDM,740,RC,95810,HCPCS,Outpatient,,,2678,2678,,,,,,Other,Not Separately Reimbursable,555.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,555.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1954.94,73,,1563.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1874.6,70,,1499.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,513.91,19.19,,411.128,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1339,50,,1071.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,513.91,1954.94,
Sleep monitoring of patient (6 years or older) in sleep lab,74095810,CDM,740,RC,95811,HCPCS,Outpatient,,,1546,1546,,,,,,Other,Not Separately Reimbursable,706.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,706.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1128.58,73,,902.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1082.2,70,,865.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,296.68,19.19,,237.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,773,50,,618.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,296.68,1128.58,
Sleep monitoring of patient (6 years or older) in sleep lab using CPAP,74095811,CDM,740,RC,90471,HCPCS,Outpatient,,,1627,1627,,,,,,Other,Not Separately Reimbursable,1732.5,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1732.5,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,1187.71,73,,950.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1138.9,70,,911.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,312.22,19.19,,249.776,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,813.5,50,,650.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,312.22,1732.5,
Immunization administration by a medical assistant or nurse,77000008,CDM,771,RC,Q2035,HCPCS,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
INFLUENZA VIRUS VAC 3 YRS OR >AFLURIA,77002035,CDM,636,RC,Q2038,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
INFLUENZA VIRUS VAC 3 YRS OR >FLUZONE,77002038,CDM,636,RC,36415,HCPCS,Outpatient,,,20,20,,,,,,Other,Not Separately Reimbursable,16.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,16.5,82.5,,13.2,percent of total billed charges,Pays at 82.5% of total Billed charges,14.6,73,,11.68,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,70,,11.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,19.19,,3.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10,50,,8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.84,16.5,
Collection of venous blood by venipuncture,77036415,CDM,300,RC,80305,HCPCS,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,9.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,9.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,18.25,73,,14.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,70,,14,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,19.19,,3.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,50,,10,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,18.25,
"DRUG SCREEN, PRESUMPTIVE, BY DIRECT OPTI",77080305,CDM,510,RC,81002,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,61.68,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,61.68,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,25.55,73,,20.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,70,,19.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,19.19,,5.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,50,,14,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,61.68,
Manual urinalysis test with examination without using microscope,77081002,CDM,307,RC,81025,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,11.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,11.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,21.9,
Urine pregnancy test,77081025,CDM,307,RC,82962,HCPCS,Outpatient,,,73,73,,,,,,Other,Not Separately Reimbursable,28.29,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,28.29,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,53.29,73,,42.632,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.1,70,,40.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.01,19.19,,11.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.5,50,,29.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.01,53.29,
GLUCOSE FINGER,77082962,CDM,300,RC,85610,HCPCS,Outpatient,,,27,27,,,,,,Other,Not Separately Reimbursable,14.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,14.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,19.71,73,,15.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.9,70,,15.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,19.19,,4.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.5,50,,10.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,19.71,
PT/INR,77085610,CDM,300,RC,87804,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
INFLUENZA A RAPID TEST (QUICKVUE),77087804,CDM,302,RC,87880,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,58.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,58.58,82.5,,46.864,percent of total billed charges,Pays at 82.5% of total Billed charges,51.83,73,,41.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,49.7,70,,39.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,19.19,,10.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.5,50,,28.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.62,58.58,
Test for strep A,77087880,CDM,306,RC,93005,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,42.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.08,82.5,,33.664,percent of total billed charges,Pays at 82.5% of total Billed charges,37.23,73,,29.784,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.7,70,,28.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,19.19,,7.832,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.5,50,,20.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.79,42.08,
ELECTROCARDIOGRAM,77093005,CDM,730,RC,94640,HCPCS,Outpatient,,,284,284,,,,,,Other,Not Separately Reimbursable,113.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,113.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,207.32,73,,165.856,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,198.8,70,,159.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.5,19.19,,43.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,142,50,,113.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54.5,207.32,
AEROSOL TREATMENT,77094640,CDM,410,RC,G0008,HCPCS,Outpatient,,,21,21,,,,,,Other,Not Separately Reimbursable,17.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,17.33,82.5,,13.864,percent of total billed charges,Pays at 82.5% of total Billed charges,15.33,73,,12.264,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.7,70,,11.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,19.19,,3.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,50,,8.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,17.33,
FLU VACCINE ADMINISTRATION,79000008,CDM,771,RC,S0020,HCPCS,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
BUPIVICAINE HCl PER 30ML,79000020,CDM,510,RC,G0101,HCPCS,Outpatient,,,37,37,,,,,,Other,Not Separately Reimbursable,30.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,30.53,82.5,,24.424,percent of total billed charges,Pays at 82.5% of total Billed charges,27.01,73,,21.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.9,70,,20.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,19.19,,5.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.5,50,,14.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,30.53,
PELVIC AND BREAST SCREENING EXAM,79000101,CDM,510,RC,G0102,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
Prostate cancer screening; digital rectal examination,79000102,CDM,521,RC,G0463,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
"ANNUAL WELLNESS VISIT,PPS SUB VISIT",79000439,CDM,510,RC,G0511,HCPCS,Outpatient,,,94,94,,,,,,Other,Not Separately Reimbursable,77.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,77.55,82.5,,62.04,percent of total billed charges,Pays at 82.5% of total Billed charges,68.62,73,,54.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.8,70,,52.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.04,19.19,,14.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47,50,,37.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.04,77.55,
"CHRONIC CARE MGMT SVC, 20 MIN",79000511,CDM,510,RC,J0696,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,28.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.88,82.5,,23.104,percent of total billed charges,Pays at 82.5% of total Billed charges,25.55,73,,20.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,70,,19.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,19.19,,5.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,50,,14,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,28.88,
ROCEPHIN IM (CEFTRIAXONE) INJ: 1 GM,79000696,CDM,636,RC,J0702,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,43.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,43.73,82.5,,34.984,percent of total billed charges,Pays at 82.5% of total Billed charges,38.69,73,,30.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.1,70,,29.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,19.19,,8.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.5,50,,21.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,43.73,
Injection to treat reaction to a drug,79000702,CDM,636,RC,J1030,HCPCS,Outpatient,,,212,212,,,,,,Other,Not Separately Reimbursable,174.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,174.9,82.5,,139.92,percent of total billed charges,Pays at 82.5% of total Billed charges,154.76,73,,123.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.4,70,,118.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.68,19.19,,32.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,106,50,,84.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.68,174.9,
DEPO-MEDROL INJECTION PER 40MG,79001030,CDM,636,RC,J1885,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
TORADOL INJECTION PER 15MG,79001885,CDM,250,RC,G2010,HCPCS,Outpatient,,,43,43,,,,,,Other,Not Separately Reimbursable,35.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,35.48,82.5,,28.384,percent of total billed charges,Pays at 82.5% of total Billed charges,31.39,73,,25.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.1,70,,24.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,19.19,,6.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.5,50,,17.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,35.48,
REMOTE EVAL RECORD VIDEO;BY PT,79002010,CDM,510,RC,Q2035,HCPCS,Outpatient,,,21,21,,,,,,Other,Not Separately Reimbursable,17.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,17.33,82.5,,13.864,percent of total billed charges,Pays at 82.5% of total Billed charges,15.33,73,,12.264,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.7,70,,11.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,19.19,,3.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,50,,8.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,17.33,
INFLUENZA VIRUS VAC 3 YRS OR >AFLURIA,79002035,CDM,636,RC,Q2037,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
INFLUENZA VIRUS VAC 3 YRS OR >FLUVIRIN,79002037,CDM,636,RC,J2405,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ONDANSETRON(ZOFRAN)INJ:4MG,79002405,CDM,636,RC,J2550,HCPCS,Outpatient,,,333,333,,,,,,Other,Not Separately Reimbursable,274.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,274.73,82.5,,219.784,percent of total billed charges,Pays at 82.5% of total Billed charges,243.09,73,,194.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,233.1,70,,186.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.9,19.19,,51.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.5,50,,133.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.9,274.73,
PHENERGAN/PROMETHAZINE UP TO 50 MG,79002550,CDM,510,RC,J2930,HCPCS,Outpatient,,,23,23,,,,,,Other,Not Separately Reimbursable,18.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,82.5,,15.184,percent of total billed charges,Pays at 82.5% of total Billed charges,16.79,73,,13.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.1,70,,12.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,19.19,,3.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.5,50,,9.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,18.98,
methylPREDNISOLONE(SoluMEDROL)INJ:125MG,79002930,CDM,510,RC,J3301,HCPCS,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
KENALOG 40 MG INJ,79003301,CDM,636,RC,J3420,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,69.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,69.3,82.5,,55.44,percent of total billed charges,Pays at 82.5% of total Billed charges,61.32,73,,49.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.8,70,,47.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,19.19,,12.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,50,,33.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,69.3,
B-12 INJECTION UP TO 1000MCG,79003420,CDM,250,RC,J7325,HCPCS,Outpatient,,,16,16,,,,,,Other,Not Separately Reimbursable,13.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13.2,82.5,,10.56,percent of total billed charges,Pays at 82.5% of total Billed charges,11.68,73,,9.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.2,70,,8.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,19.19,,2.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8,50,,6.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,13.2,
SYNVISC-ONE PFS 6ML INJECTION,79007325,CDM,636,RC,10060,HCPCS,Outpatient,,,2595,2595,,,,,,Other,Not Separately Reimbursable,2140.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2140.88,82.5,,1712.704,percent of total billed charges,Pays at 82.5% of total Billed charges,1894.35,73,,1515.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1816.5,70,,1453.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,497.98,19.19,,398.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1297.5,50,,1038,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,497.98,2140.88,
Incision and drainage of abscess; simple or single and complex or multiple,79010060,CDM,510,RC,10061,HCPCS,Outpatient,,,106,106,,,,,,Other,Not Separately Reimbursable,87.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,87.45,82.5,,69.96,percent of total billed charges,Pays at 82.5% of total Billed charges,77.38,73,,61.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.2,70,,59.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.34,19.19,,16.272,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53,50,,42.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.34,87.45,
I&D ABCESS COMPLICATED OR MULTIPLE,79010061,CDM,510,RC,10120,HCPCS,Outpatient,,,197,197,,,,,,Other,Not Separately Reimbursable,162.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,162.53,82.5,,130.024,percent of total billed charges,Pays at 82.5% of total Billed charges,143.81,73,,115.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.9,70,,110.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,19.19,,30.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.5,50,,78.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,162.53,
I&D REMOVE FB SIMPLE,79010120,CDM,510,RC,10121,HCPCS,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,93.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,93.23,82.5,,74.584,percent of total billed charges,Pays at 82.5% of total Billed charges,82.49,73,,65.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.1,70,,63.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,19.19,,17.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.5,50,,45.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,93.23,
I&D REMOVE FB COMPLEX,79010121,CDM,510,RC,10160,HCPCS,Outpatient,,,205,205,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,149.65,73,,119.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.5,70,,114.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,19.19,,31.472,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.5,50,,82,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,1319.85,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",79010160,CDM,510,RC,11200,HCPCS,Outpatient,,,105,105,,,,,,Other,Not Separately Reimbursable,86.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,86.63,82.5,,69.304,percent of total billed charges,Pays at 82.5% of total Billed charges,76.65,73,,61.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.5,70,,58.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,19.19,,16.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,50,,42,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,86.63,
"Removal of skin tags, multiple fibrocutaneous tags, any area",79011200,CDM,510,RC,11403,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
EXC-BENIGN TRUCK/ARM/LEGS 2. 1-3.0 CM,79011403,CDM,510,RC,11730,HCPCS,Outpatient,,,163,163,,,,,,Other,Not Separately Reimbursable,134.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,134.48,82.5,,107.584,percent of total billed charges,Pays at 82.5% of total Billed charges,118.99,73,,95.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,114.1,70,,91.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.28,19.19,,25.024,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.5,50,,65.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.28,134.48,
Separation and removal of the entire nail plate or a portion of nail plate,79011730,CDM,510,RC,11740,HCPCS,Outpatient,,,61,61,,,,,,Other,Not Separately Reimbursable,50.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,50.33,82.5,,40.264,percent of total billed charges,Pays at 82.5% of total Billed charges,44.53,73,,35.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.7,70,,34.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,19.19,,9.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.5,50,,24.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,50.33,
EVACUATION OF SUBUNGAL HEMATOMA,79011740,CDM,510,RC,11900,HCPCS,Outpatient,,,36,36,,,,,,Other,Not Separately Reimbursable,29.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,29.7,82.5,,23.76,percent of total billed charges,Pays at 82.5% of total Billed charges,26.28,73,,21.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.2,70,,20.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,19.19,,5.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18,50,,14.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,29.7,
Injections to remove up to 7 lesions on the skin,79011900,CDM,510,RC,11901,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,28.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.88,82.5,,23.104,percent of total billed charges,Pays at 82.5% of total Billed charges,25.55,73,,20.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,70,,19.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,19.19,,5.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,50,,14,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,28.88,
ADDED SKIN LESIONS INJECTION,79011901,CDM,510,RC,12021,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
TRMT OF SUPERFICIAL WOUND W/PACKING,79012021,CDM,510,RC,17110,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,982.8,
Destruction of 1-14 common or plantar warts,79017110,CDM,510,RC,17111,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,54.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,54.45,82.5,,43.56,percent of total billed charges,Pays at 82.5% of total Billed charges,48.18,73,,38.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.2,70,,36.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,19.19,,10.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33,50,,26.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,54.45,
Destruction of >15 common or plantar warts,79017111,CDM,510,RC,J7325,HCPCS,Outpatient,,,82,82,,,,,,Other,Not Separately Reimbursable,67.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,67.65,82.5,,54.12,percent of total billed charges,Pays at 82.5% of total Billed charges,59.86,73,,47.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.4,70,,45.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,19.19,,12.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41,50,,32.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,67.65,
SYNVISC PFS 2ML INJ 3 SYRINGES,79017325,CDM,636,RC,20526,HCPCS,Outpatient,,,2595,2595,,,,,,Other,Not Separately Reimbursable,2140.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,2140.88,82.5,,1712.704,percent of total billed charges,Pays at 82.5% of total Billed charges,1894.35,73,,1515.48,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1816.5,70,,1453.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,497.98,19.19,,398.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1297.5,50,,1038,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,497.98,2140.88,
"INJECTION, THERAPEUTIC, CARPAL TUNNEL",79020526,CDM,510,RC,20550,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
Injection of medication into a tendon or ligament,79020550,CDM,510,RC,20551,HCPCS,Outpatient,,,44,44,,,,,,Other,Not Separately Reimbursable,36.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,36.3,82.5,,29.04,percent of total billed charges,Pays at 82.5% of total Billed charges,32.12,73,,25.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.8,70,,24.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,19.19,,6.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22,50,,17.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,36.3,
Injection of medication into the tendon/ligament origin,79020551,CDM,510,RC,20552,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
INJ TRIGGER POINT 1/2 MUSCL,79020552,CDM,510,RC,20553,HCPCS,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
Injection of medication into an area that triggers pain,79020553,CDM,510,RC,20600,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
Draining or injecting medication into a small joint/bursa without ultrasound,79020600,CDM,510,RC,20604,HCPCS,Outpatient,,,39,39,,,,,,Other,Not Separately Reimbursable,32.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,32.18,82.5,,25.744,percent of total billed charges,Pays at 82.5% of total Billed charges,28.47,73,,22.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.3,70,,21.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,19.19,,5.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.5,50,,15.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,32.18,
ARTHROCESPIRATION/INJ;SM JNT/BUR W/US,79020604,CDM,510,RC,20605,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
Draining or injecting medication into a large joint/bursa without ultrasound,79020605,CDM,510,RC,20606,HCPCS,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
ARTHROCESPIRA/INJ; INTER JNT/BUR W/US,79020606,CDM,510,RC,20610,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
Draining or injecting medication into a major joint/bursa without ultrasound,79020610,CDM,510,RC,20611,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
ARTHROCESPIRA/INJ; MAJ JNT/BUR W/US,79020611,CDM,510,RC,20612,HCPCS,Outpatient,,,68,68,,,,,,Other,Not Separately Reimbursable,56.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.1,82.5,,44.88,percent of total billed charges,Pays at 82.5% of total Billed charges,49.64,73,,39.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.6,70,,38.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,19.19,,10.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34,50,,27.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,56.1,
Removal of fluid or injection of medication into a ganglion cyst,79020612,CDM,510,RC,26605,HCPCS,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,38.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,38.78,82.5,,31.024,percent of total billed charges,Pays at 82.5% of total Billed charges,34.31,73,,27.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.9,70,,26.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,19.19,,7.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.5,50,,18.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,38.78,
CLSD TRMT OF METACARPAL FX W/MANIPULATIO,79026605,CDM,510,RC,26641,HCPCS,Outpatient,,,321,321,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,234.33,73,,187.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,224.7,70,,179.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,19.19,,49.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,160.5,50,,128.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,1319.85,
TREAT THUMB DISLOCATION,79026641,CDM,510,RC,26725,HCPCS,Outpatient,,,338,338,,,,,,Other,Not Separately Reimbursable,278.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,278.85,82.5,,223.08,percent of total billed charges,Pays at 82.5% of total Billed charges,246.74,73,,197.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,236.6,70,,189.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.86,19.19,,51.888,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,169,50,,135.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,64.86,278.85,
CLSD TRMT W/MANIPUL W/WO SKIN/SKEL TRACT,79026725,CDM,510,RC,27328,HCPCS,Outpatient,,,292,292,,,,,,Other,Not Separately Reimbursable,240.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,240.9,82.5,,192.72,percent of total billed charges,Pays at 82.5% of total Billed charges,213.16,73,,170.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,204.4,70,,163.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.03,19.19,,44.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,146,50,,116.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.03,240.9,
"EXC TUMOR,SFT TIS THIGH/KNEE,SUBFASC<5CM",79027328,CDM,510,RC,29065,HCPCS,Outpatient,,,614,614,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,448.22,73,,358.576,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,429.8,70,,343.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.83,19.19,,94.264,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,307,50,,245.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.83,1508.85,
APPLICATION OF LONG ARM CAST,79029065,CDM,510,RC,29075,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,62.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,62.7,82.5,,50.16,percent of total billed charges,Pays at 82.5% of total Billed charges,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,62.7,
APPLICATION OF FOREARM CAST,79029075,CDM,510,RC,29085,HCPCS,Outpatient,,,69,69,,,,,,Other,Not Separately Reimbursable,56.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.93,82.5,,45.544,percent of total billed charges,Pays at 82.5% of total Billed charges,50.37,73,,40.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.3,70,,38.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.24,19.19,,10.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,50,,27.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.24,56.93,
APPLICATION OF HAND/WRIST CAST,79029085,CDM,510,RC,29105,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
APPLICATION OF LONG ARM SPLINT,79029105,CDM,510,RC,29125,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,54.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,54.45,82.5,,43.56,percent of total billed charges,Pays at 82.5% of total Billed charges,48.18,73,,38.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.2,70,,36.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,19.19,,10.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33,50,,26.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,54.45,
APPLICATION OF FOREARM SPLINT,79029125,CDM,510,RC,29130,HCPCS,Outpatient,,,44,44,,,,,,Other,Not Separately Reimbursable,36.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,36.3,82.5,,29.04,percent of total billed charges,Pays at 82.5% of total Billed charges,32.12,73,,25.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.8,70,,24.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,19.19,,6.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22,50,,17.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,36.3,
APPLICATION OF FINGER SPLINT,79029130,CDM,510,RC,29405,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,26.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,26.4,82.5,,21.12,percent of total billed charges,Pays at 82.5% of total Billed charges,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,26.4,
APPL OF SHORT LEG CAST BELOW KNEE TO TOE,79029405,CDM,510,RC,29505,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,54.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,54.45,82.5,,43.56,percent of total billed charges,Pays at 82.5% of total Billed charges,48.18,73,,38.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.2,70,,36.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,19.19,,10.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33,50,,26.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,54.45,
APPLICATION OF LONG LEG SPLINT,79029505,CDM,510,RC,29515,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
APPLICATION OF LOWER LEG SPLINT,79029515,CDM,510,RC,69210,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
Removal of ear wax from one or both ears,79069210,CDM,510,RC,76942,HCPCS,Outpatient,,,36,36,,,,,,Other,Not Separately Reimbursable,29.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,29.7,82.5,,23.76,percent of total billed charges,Pays at 82.5% of total Billed charges,26.28,73,,21.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.2,70,,20.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,19.19,,5.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18,50,,14.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,29.7,
US GUIDANCE FOR NEEDLE PLACEMENT,79076942,CDM,510,RC,81002,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,161.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,161.03,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,161.03,
Manual urinalysis test with examination without using microscope,79081002,CDM,307,RC,81025,HCPCS,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,11.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,11.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,11.43,
Urine pregnancy test,79081025,CDM,307,RC,82962,HCPCS,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,28.29,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,28.29,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,28.29,
GLUCOSE FINGER,79082962,CDM,300,RC,83036,HCPCS,Outpatient,,,8,8,,,,,,Other,Not Separately Reimbursable,14.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,14.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,5.84,73,,4.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.6,70,,4.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,19.19,,1.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4,50,,3.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,14.14,
A1C-GLYCOSYLATED,79083036,CDM,300,RC,87804,HCPCS,Outpatient,,,27,27,,,,,,Other,Not Separately Reimbursable,22.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,22.28,82.5,,17.824,percent of total billed charges,Pays at 82.5% of total Billed charges,19.71,73,,15.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.9,70,,15.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,19.19,,4.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.5,50,,10.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,22.28,
INFLUENZA A RAPID TEST (QUICKVUE),79087804,CDM,302,RC,87880,HCPCS,Outpatient,,,39,39,,,,,,Other,Not Separately Reimbursable,32.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,32.18,82.5,,25.744,percent of total billed charges,Pays at 82.5% of total Billed charges,28.47,73,,22.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.3,70,,21.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,19.19,,5.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.5,50,,15.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,32.18,
Test for strep A,79087880,CDM,306,RC,90471,HCPCS,Outpatient,,,39,39,,,,,,Other,Not Separately Reimbursable,32.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,32.18,82.5,,25.744,percent of total billed charges,Pays at 82.5% of total Billed charges,28.47,73,,22.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.3,70,,21.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,19.19,,5.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.5,50,,15.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,32.18,
Immunization administration by a medical assistant or nurse,79090471,CDM,771,RC,90656,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
Flu shot-high dose for 2019-2020 flu season given by injection,79090656,CDM,636,RC,90674,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
FLU VACCINE PFS: 0.5ML FLUCELVAX,79090661,CDM,636,RC,90662,HCPCS,Outpatient,,,235,235,,,,,,Other,Not Separately Reimbursable,193.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,193.88,82.5,,155.104,percent of total billed charges,Pays at 82.5% of total Billed charges,171.55,73,,137.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,164.5,70,,131.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.1,19.19,,36.08,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.5,50,,94,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.1,193.88,
FLU(HIGH DOSE>65 YO)VACCINE:0.5ML,79090662,CDM,636,RC,90670,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
PREVNAR-13(PNEUMOCOCCAL)VACCINE INJ,79090670,CDM,636,RC,90686,HCPCS,Outpatient,,,474,474,,,,,,Other,Not Separately Reimbursable,391.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,391.05,82.5,,312.84,percent of total billed charges,Pays at 82.5% of total Billed charges,346.02,73,,276.816,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,331.8,70,,265.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.96,19.19,,72.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,237,50,,189.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.96,391.05,
Flu shot-high dose for 2019-2020 flu season given by injection for people >65,79090686,CDM,636,RC,90732,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
pneumococcal Pneumococcal vaccine,79090732,CDM,636,RC,93005,HCPCS,Outpatient,,,474,474,,,,,,Other,Not Separately Reimbursable,391.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,391.05,82.5,,312.84,percent of total billed charges,Pays at 82.5% of total Billed charges,346.02,73,,276.816,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,331.8,70,,265.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.96,19.19,,72.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,237,50,,189.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.96,391.05,
ELECTROCARDIOGRAM,79093005,CDM,730,RC,94640,HCPCS,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,113.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,113.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,13.87,73,,11.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.3,70,,10.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,19.19,,2.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.5,50,,7.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,113.84,
AEROSOL TREATMENT,79094640,CDM,410,RC,95115,HCPCS,Outpatient,,,41,41,,,,,,Other,Not Separately Reimbursable,33.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33.83,82.5,,27.064,percent of total billed charges,Pays at 82.5% of total Billed charges,29.93,73,,23.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.7,70,,22.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,19.19,,6.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.5,50,,16.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,33.83,
Allergy shot-1 shot,79095115,CDM,510,RC,95117,HCPCS,Outpatient,,,26,26,,,,,,Other,Not Separately Reimbursable,21.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,21.45,82.5,,17.16,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,73,,15.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.2,70,,14.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,19.19,,3.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13,50,,10.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,21.45,
Multiple allergy shots,79095117,CDM,510,RC,96372,HCPCS,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,25.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,25.58,82.5,,20.464,percent of total billed charges,Pays at 82.5% of total Billed charges,22.63,73,,18.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.7,70,,17.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,19.19,,4.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.5,50,,12.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,25.58,
INJECTION ADMINISTRATION,79096372,CDM,510,RC,99183,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
HBO THERAPY ATTENDANCE/SUPERVISION,79099183,CDM,510,RC,99201,HCPCS,Outpatient,,,102,102,,,,,,Other,Not Separately Reimbursable,84.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,84.15,82.5,,67.32,percent of total billed charges,Pays at 82.5% of total Billed charges,74.46,73,,59.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.4,70,,57.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,19.19,,15.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51,50,,40.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,84.15,
OFFICE VISIT 10 MIN NEW,79099201,CDM,510,RC,99202,HCPCS,Outpatient,,,22,22,,,,,,Other,Not Separately Reimbursable,18.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.15,82.5,,14.52,percent of total billed charges,Pays at 82.5% of total Billed charges,16.06,73,,12.848,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.4,70,,12.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,19.19,,3.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11,50,,8.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.22,18.15,
"New patient office or other outpatient visit, typically 10 minutes",79099202,CDM,510,RC,99203,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
"New patient office or other outpatient visit, typically 30 min",79099203,CDM,510,RC,99204,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,69.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,69.3,82.5,,55.44,percent of total billed charges,Pays at 82.5% of total Billed charges,61.32,73,,49.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.8,70,,47.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,19.19,,12.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,50,,33.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,69.3,
"New patient office of other outpatient visit, typically 45 min",79099204,CDM,510,RC,99205,HCPCS,Outpatient,,,141,141,,,,,,Other,Not Separately Reimbursable,116.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,116.33,82.5,,93.064,percent of total billed charges,Pays at 82.5% of total Billed charges,102.93,73,,82.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.7,70,,78.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,19.19,,21.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.5,50,,56.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,116.33,
"New patient office of other outpatient visit, typically 60 min",79099205,CDM,510,RC,99211,HCPCS,Outpatient,,,184,184,,,,,,Other,Not Separately Reimbursable,151.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,151.8,82.5,,121.44,percent of total billed charges,Pays at 82.5% of total Billed charges,134.32,73,,107.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.8,70,,103.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,19.19,,28.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92,50,,73.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,151.8,
Outpatient visit of established patient not requiring a physician,79099211,CDM,510,RC,99212,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
Outpatient visit of established patient requiring a physician,79099212,CDM,510,RC,99213,HCPCS,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,23.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.1,82.5,,18.48,percent of total billed charges,Pays at 82.5% of total Billed charges,20.44,73,,16.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.6,70,,15.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,19.19,,4.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,50,,11.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,23.1,
"Established patient office or other outpatient visit, typically 15 minutes",79099213,CDM,510,RC,99214,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
"Established patient office or other outpatient visit, typically 25 minutes",79099214,CDM,510,RC,99215,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
"Established patient office or other outpatient, visit typically 40 minutes",79099215,CDM,510,RC,99495,HCPCS,Outpatient,,,94,94,,,,,,Other,Not Separately Reimbursable,77.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,77.55,82.5,,62.04,percent of total billed charges,Pays at 82.5% of total Billed charges,68.62,73,,54.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.8,70,,52.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.04,19.19,,14.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47,50,,37.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.04,77.55,
TRANS CARE MGMT 14 DAY DISCH,79099495,CDM,510,RC,99496,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
TRANS CARE MGMT 7 DAY DISCH,79099496,CDM,510,RC,99201,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately Reimbursable,143.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,143.55,82.5,,114.84,percent of total billed charges,Pays at 82.5% of total Billed charges,127.02,73,,101.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121.8,70,,97.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.39,19.19,,26.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87,50,,69.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.39,143.55,
OFFICE VISIT 10 MIN NEW,79199201,CDM,510,RC,99202,HCPCS,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,23.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.93,82.5,,19.144,percent of total billed charges,Pays at 82.5% of total Billed charges,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,23.93,
OFFICE VISIT 20 MIN NEW,79199202,CDM,510,RC,99203,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
OFFICE VISIT 30 MIN NEW,79199203,CDM,510,RC,99204,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,69.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,69.3,82.5,,55.44,percent of total billed charges,Pays at 82.5% of total Billed charges,61.32,73,,49.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.8,70,,47.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,19.19,,12.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,50,,33.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,69.3,
OFFICE VISIT 45 MIN NEW,79199204,CDM,510,RC,99205,HCPCS,Outpatient,,,141,141,,,,,,Other,Not Separately Reimbursable,116.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,116.33,82.5,,93.064,percent of total billed charges,Pays at 82.5% of total Billed charges,102.93,73,,82.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.7,70,,78.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,19.19,,21.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.5,50,,56.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,116.33,
OFFICE VISIT 60 MIN NEW,79199205,CDM,510,RC,99211,HCPCS,Outpatient,,,184,184,,,,,,Other,Not Separately Reimbursable,151.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,151.8,82.5,,121.44,percent of total billed charges,Pays at 82.5% of total Billed charges,134.32,73,,107.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.8,70,,103.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,19.19,,28.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92,50,,73.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,151.8,
OFFICE VISIT 5 MIN EST,79199211,CDM,510,RC,99212,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
OFFICE VISIT 10 MIN EST,79199212,CDM,510,RC,99213,HCPCS,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,23.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.1,82.5,,18.48,percent of total billed charges,Pays at 82.5% of total Billed charges,20.44,73,,16.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.6,70,,15.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,19.19,,4.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,50,,11.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,23.1,
OFFICE VISIT 15 MIN EST,79199213,CDM,510,RC,99214,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
OFFICE VISIT 25 MIN EST,79199214,CDM,510,RC,99215,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
OFFICE VISIT 40 MIN EST,79199215,CDM,510,RC,87804,HCPCS,Outpatient,,,94,94,,,,,,Other,Not Separately Reimbursable,77.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,77.55,82.5,,62.04,percent of total billed charges,Pays at 82.5% of total Billed charges,68.62,73,,54.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.8,70,,52.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.04,19.19,,14.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47,50,,37.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.04,77.55,
INFLUENZA B RAPID TEST (QUICKVUE),79387804,CDM,302,RC,S0077,HCPCS,Outpatient,,,39,39,,,,,,Other,Not Separately Reimbursable,32.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,32.18,82.5,,25.744,percent of total billed charges,Pays at 82.5% of total Billed charges,28.47,73,,22.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.3,70,,21.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,19.19,,5.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.5,50,,15.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,32.18,
CLEOCIN(CLINDAMYCIN)INJ:300MG,82000077,CDM,250,RC,G0179,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
PHY RECERT FOR MCR COVERED HH SVCS,82000179,CDM,510,RC,J0696,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
ROCEPHIN IM (CEFTRIAXONE)INJ: 1 GM,82000696,CDM,636,RC,J1030,HCPCS,Outpatient,,,212,212,,,,,,Other,Not Separately Reimbursable,174.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,174.9,82.5,,139.92,percent of total billed charges,Pays at 82.5% of total Billed charges,154.76,73,,123.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.4,70,,118.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.68,19.19,,32.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,106,50,,84.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.68,174.9,
DEPO-MEDROL INJECTION PER 40MG,82001030,CDM,636,RC,J1100,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
DECADRON(DEXAMETHASONE)INJ:1MG,82001100,CDM,250,RC,J1885,HCPCS,Outpatient,,,7,7,,,,,,Other,Not Separately Reimbursable,5.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,5.78,82.5,,4.624,percent of total billed charges,Pays at 82.5% of total Billed charges,5.11,73,,4.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.9,70,,3.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,19.19,,1.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,50,,2.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,5.78,
TORADOL INJECTION PER 15MG,82001885,CDM,510,RC,Q2037,HCPCS,Outpatient,,,43,43,,,,,,Other,Not Separately Reimbursable,35.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,35.48,82.5,,28.384,percent of total billed charges,Pays at 82.5% of total Billed charges,31.39,73,,25.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.1,70,,24.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,19.19,,6.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.5,50,,17.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,35.48,
INFLUENZA VIRUS VAC 3 YRS OR >FLUVIRIN,82002037,CDM,636,RC,J2405,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
ONDANSETRON(ZOFRAN)INJ:4MG,82002405,CDM,636,RC,J3301,HCPCS,Outpatient,,,333,333,,,,,,Other,Not Separately Reimbursable,274.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,274.73,82.5,,219.784,percent of total billed charges,Pays at 82.5% of total Billed charges,243.09,73,,194.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,233.1,70,,186.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.9,19.19,,51.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.5,50,,133.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.9,274.73,
KENALOG 40 MG INJ,82003301,CDM,636,RC,10021,HCPCS,Outpatient,,,83,83,,,,,,Other,Not Separately Reimbursable,68.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,68.48,82.5,,54.784,percent of total billed charges,Pays at 82.5% of total Billed charges,60.59,73,,48.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.1,70,,46.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.93,19.19,,12.744,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.5,50,,33.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.93,68.48,
Fine Needle Aspiration Biopsy without imaging,82010021,CDM,510,RC,10160,HCPCS,Outpatient,,,77,77,,,,,,Other,Not Separately Reimbursable,63.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,63.53,82.5,,50.824,percent of total billed charges,Pays at 82.5% of total Billed charges,56.21,73,,44.968,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.9,70,,43.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,19.19,,11.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,50,,30.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.78,63.53,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",82010160,CDM,510,RC,11056,HCPCS,Outpatient,,,105,105,,,,,,Other,Not Separately Reimbursable,86.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,86.63,82.5,,69.304,percent of total billed charges,Pays at 82.5% of total Billed charges,76.65,73,,61.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.5,70,,58.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,19.19,,16.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,50,,42,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,86.63,
Paring or cutting of benign hyperkeratotic lesion,82011056,CDM,510,RC,11057,HCPCS,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,20.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,20.63,82.5,,16.504,percent of total billed charges,Pays at 82.5% of total Billed charges,18.25,73,,14.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,70,,14,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,19.19,,3.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.5,50,,10,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.8,20.63,
EXC BENIGN HYPERTROPHIC SKIN LES > 4,82011057,CDM,510,RC,11300,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,27.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,27.23,82.5,,21.784,percent of total billed charges,Pays at 82.5% of total Billed charges,24.09,73,,19.272,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.1,70,,18.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,19.19,,5.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,50,,13.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.33,27.23,
"SHAVING OF EPID LES;TRUNK,ARM,LEG <.50CM",82011300,CDM,510,RC,11305,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33,82.5,,26.4,percent of total billed charges,Pays at 82.5% of total Billed charges,29.2,73,,23.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,70,,22.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,19.19,,6.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20,50,,16,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.68,33,
"SHAVING OF EPID LES;SCALP,NECK <.50CM",82011305,CDM,510,RC,11306,HCPCS,Outpatient,,,43,43,,,,,,Other,Not Separately Reimbursable,35.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,35.48,82.5,,28.384,percent of total billed charges,Pays at 82.5% of total Billed charges,31.39,73,,25.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.1,70,,24.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,19.19,,6.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.5,50,,17.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,35.48,
"SHAVING OF EPID LES;SCALP,NECK .6-1.0CM",82011306,CDM,510,RC,11310,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,47.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.85,82.5,,38.28,percent of total billed charges,Pays at 82.5% of total Billed charges,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,47.85,
"SHAV EPID/DERM SGL LES,F/E/EL/N/L .5CM<",82011310,CDM,510,RC,11400,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,43.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,43.73,82.5,,34.984,percent of total billed charges,Pays at 82.5% of total Billed charges,38.69,73,,30.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.1,70,,29.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,19.19,,8.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.5,50,,21.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,43.73,
EXC TR-EXT B9+MARG 0.5<CM,82011400,CDM,510,RC,11401,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,73.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,73.43,82.5,,58.744,percent of total billed charges,Pays at 82.5% of total Billed charges,64.97,73,,51.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.3,70,,49.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,19.19,,13.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.5,50,,35.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,73.43,
Under Excision-Benign Lesions Procedures on the Skin 0.6-1 CM,82011401,CDM,510,RC,11403,HCPCS,Outpatient,,,114,114,,,,,,Other,Not Separately Reimbursable,94.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,94.05,82.5,,75.24,percent of total billed charges,Pays at 82.5% of total Billed charges,83.22,73,,66.576,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.8,70,,63.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.88,19.19,,17.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57,50,,45.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.88,94.05,
EXC TR-EXT B9+MARG 2.1-3CM,82011403,CDM,510,RC,11406,HCPCS,Outpatient,,,163,163,,,,,,Other,Not Separately Reimbursable,134.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,134.48,82.5,,107.584,percent of total billed charges,Pays at 82.5% of total Billed charges,118.99,73,,95.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,114.1,70,,91.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.28,19.19,,25.024,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.5,50,,65.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.28,134.48,
EXC TR-EXT B9+MARG >4.0CM,82011406,CDM,510,RC,11420,HCPCS,Outpatient,,,277,277,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,202.21,73,,161.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,193.9,70,,155.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.16,19.19,,42.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,138.5,50,,110.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.16,1319.85,
EXC H-F-NK-SP B9+MARG 0.5<,82011420,CDM,510,RC,11423,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,73.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,73.43,82.5,,58.744,percent of total billed charges,Pays at 82.5% of total Billed charges,64.97,73,,51.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.3,70,,49.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,19.19,,13.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.5,50,,35.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.08,73.43,
EXC H-F-NK-SP B9+MARG 2.1-3CM,82011423,CDM,510,RC,11424,HCPCS,Outpatient,,,173,173,,,,,,Other,Not Separately Reimbursable,142.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,142.73,82.5,,114.184,percent of total billed charges,Pays at 82.5% of total Billed charges,126.29,73,,101.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121.1,70,,96.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.2,19.19,,26.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.5,50,,69.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.2,142.73,
EXC H-F-NK-SP B9+MARG 3.1-4CM,82011424,CDM,510,RC,11426,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,146,73,,116.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,140,70,,112,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,19.19,,30.704,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100,50,,80,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.38,1319.85,
EXC H-F-NK-SP B9+MARG >4CM,82011426,CDM,510,RC,11440,HCPCS,Outpatient,,,309,309,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,225.57,73,,180.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216.3,70,,173.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.3,19.19,,47.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,154.5,50,,123.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.3,1319.85,
EXC-BENIGN FACE/EARS/ETC .5CM OR <,82011440,CDM,510,RC,11442,HCPCS,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,93.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,93.23,82.5,,74.584,percent of total billed charges,Pays at 82.5% of total Billed charges,82.49,73,,65.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.1,70,,63.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,19.19,,17.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.5,50,,45.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,93.23,
EXC BENIGN FACE/EARS/ETC 1.1-2.0 CM,82011442,CDM,510,RC,11444,HCPCS,Outpatient,,,160,160,,,,,,Other,Not Separately Reimbursable,132,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132,82.5,,105.6,percent of total billed charges,Pays at 82.5% of total Billed charges,116.8,73,,93.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112,70,,89.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,19.19,,24.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80,50,,64,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.7,132,
EXC FACE-MM B9+MARG 3.1-4CM,82011444,CDM,510,RC,11446,HCPCS,Outpatient,,,252,252,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,183.96,73,,147.168,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,176.4,70,,141.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.36,19.19,,38.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,126,50,,100.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.36,982.8,
EXC FACE-MM B9+MARG >4.0CM,82011446,CDM,510,RC,11600,HCPCS,Outpatient,,,362,362,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,264.26,73,,211.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,253.4,70,,202.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.47,19.19,,55.576,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,181,50,,144.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.47,1319.85,
EXC TR-EXT MAL+MARG 0.5<CM,82011600,CDM,510,RC,11601,HCPCS,Outpatient,,,133,133,,,,,,Other,Not Separately Reimbursable,109.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,109.73,82.5,,87.784,percent of total billed charges,Pays at 82.5% of total Billed charges,97.09,73,,77.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.1,70,,74.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.52,19.19,,20.416,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,66.5,50,,53.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.52,109.73,
EXC TR-EXT MAL+MARG 0.6-1CM,82011601,CDM,510,RC,11602,HCPCS,Outpatient,,,165,165,,,,,,Other,Not Separately Reimbursable,136.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,136.13,82.5,,108.904,percent of total billed charges,Pays at 82.5% of total Billed charges,120.45,73,,96.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.5,70,,92.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.66,19.19,,25.328,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.5,50,,66,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.66,136.13,
Excision-Malignant Lesions,82011602,CDM,510,RC,11603,HCPCS,Outpatient,,,182,182,,,,,,Other,Not Separately Reimbursable,150.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,150.15,82.5,,120.12,percent of total billed charges,Pays at 82.5% of total Billed charges,132.86,73,,106.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,127.4,70,,101.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.93,19.19,,27.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,50,,72.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.93,150.15,
EXC TR-EXT MAL+MARG 2.1-3CM,82011603,CDM,510,RC,11604,HCPCS,Outpatient,,,219,219,,,,,,Other,Not Separately Reimbursable,180.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,180.68,82.5,,144.544,percent of total billed charges,Pays at 82.5% of total Billed charges,159.87,73,,127.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153.3,70,,122.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.03,19.19,,33.624,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.5,50,,87.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.03,180.68,
EXC TR-EXT MAL+MARG 3.1-4CM,82011604,CDM,510,RC,11606,HCPCS,Outpatient,,,241,241,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,175.93,73,,140.744,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,168.7,70,,134.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.25,19.19,,37,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,120.5,50,,96.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.25,1319.85,
EXC TR-EXT MAL+MARG >4CM,82011606,CDM,510,RC,11620,HCPCS,Outpatient,,,361,361,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,263.53,73,,210.824,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,252.7,70,,202.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.28,19.19,,55.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,180.5,50,,144.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.28,1319.85,
EXC F-NK-SP MAL+MARG 0.5<,82011620,CDM,510,RC,11621,HCPCS,Outpatient,,,134,134,,,,,,Other,Not Separately Reimbursable,110.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,110.55,82.5,,88.44,percent of total billed charges,Pays at 82.5% of total Billed charges,97.82,73,,78.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,93.8,70,,75.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.71,19.19,,20.568,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67,50,,53.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.71,110.55,
EXC F-NK-SP MAL+MARG 0.6-1CM,82011621,CDM,510,RC,11623,HCPCS,Outpatient,,,166,166,,,,,,Other,Not Separately Reimbursable,136.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,136.95,82.5,,109.56,percent of total billed charges,Pays at 82.5% of total Billed charges,121.18,73,,96.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.2,70,,92.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.86,19.19,,25.488,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83,50,,66.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.86,136.95,
EXC F-NK-SP MAL+MARG 2.1-3CM,82011623,CDM,510,RC,11624,HCPCS,Outpatient,,,237,237,,,,,,Other,Not Separately Reimbursable,195.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,195.53,82.5,,156.424,percent of total billed charges,Pays at 82.5% of total Billed charges,173.01,73,,138.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165.9,70,,132.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.48,19.19,,36.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,118.5,50,,94.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.48,195.53,
EXC MAL LES SP/NCK/HD/FACE/GENIT 3.1-4CM,82011624,CDM,510,RC,11626,HCPCS,Outpatient,,,269,269,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,196.37,73,,157.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,188.3,70,,150.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.62,19.19,,41.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,134.5,50,,107.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.62,1319.85,
EXC F-NK-SP MAL+MARG >4CM,82011626,CDM,510,RC,11640,HCPCS,Outpatient,,,330,330,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,240.9,73,,192.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,231,70,,184.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.33,19.19,,50.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,165,50,,132,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.33,1319.85,
EXC MALIG LES +MARGINS F/E/E/N/L < .5CM,82011640,CDM,510,RC,11641,HCPCS,Outpatient,,,139,139,,,,,,Other,Not Separately Reimbursable,114.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,114.68,82.5,,91.744,percent of total billed charges,Pays at 82.5% of total Billed charges,101.47,73,,81.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,97.3,70,,77.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.67,19.19,,21.336,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69.5,50,,55.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.67,114.68,
EXC MALIG LES +MARGINS F/E/E/N/L .6-1CM,82011641,CDM,510,RC,11644,HCPCS,Outpatient,,,173,173,,,,,,Other,Not Separately Reimbursable,142.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,142.73,82.5,,114.184,percent of total billed charges,Pays at 82.5% of total Billed charges,126.29,73,,101.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121.1,70,,96.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.2,19.19,,26.56,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,86.5,50,,69.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.2,142.73,
EXC F/E/E/N/L MAL+MARG 3.1-4CM,82011644,CDM,510,RC,12002,HCPCS,Outpatient,,,319,319,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,232.87,73,,186.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,223.3,70,,178.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.22,19.19,,48.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,159.5,50,,127.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.22,1319.85,
REPAIR OF SUPERFICIAL WOUND 2.6-7.5CM,82012002,CDM,510,RC,12034,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,54.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,54.45,82.5,,43.56,percent of total billed charges,Pays at 82.5% of total Billed charges,48.18,73,,38.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.2,70,,36.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,19.19,,10.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33,50,,26.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,54.45,
INTMD RPR S/A/T/EXT 7.6-12.5,82012034,CDM,510,RC,12035,HCPCS,Outpatient,,,232,232,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,169.36,73,,135.488,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,162.4,70,,129.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.52,19.19,,35.616,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116,50,,92.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.52,1319.85,
INTMD RPR S/A/T/EXT 12.6-20CM,82012035,CDM,510,RC,12036,HCPCS,Outpatient,,,269,269,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,196.37,73,,157.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,188.3,70,,150.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.62,19.19,,41.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,134.5,50,,107.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.62,1319.85,
INTMD RPR S/A/T/EXT 20.1-30CM,82012036,CDM,510,RC,12037,HCPCS,Outpatient,,,315,315,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,229.95,73,,183.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,220.5,70,,176.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.45,19.19,,48.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,157.5,50,,126,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.45,1319.85,
INTMD RPR S/A/T/EXT >30.0CM,82012037,CDM,510,RC,12053,HCPCS,Outpatient,,,370,370,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,270.1,73,,216.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,259,70,,207.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,19.19,,56.8,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,185,50,,148,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71,1319.85,
INTMD RPR FACE/MM 5.1-7.5CM,82012053,CDM,510,RC,12054,HCPCS,Outpatient,,,243,243,,,,,,Other,Not Separately Reimbursable,200.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,200.48,82.5,,160.384,percent of total billed charges,Pays at 82.5% of total Billed charges,177.39,73,,141.912,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.1,70,,136.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.63,19.19,,37.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121.5,50,,97.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.63,200.48,
INTMD RPR FACE/MM 7.6-12.5CM,82012054,CDM,510,RC,12055,HCPCS,Outpatient,,,249,249,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,181.77,73,,145.416,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,174.3,70,,139.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.78,19.19,,38.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,124.5,50,,99.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.78,1319.85,
INTMD RPR FACE/MM 12.6-20CM,82012055,CDM,510,RC,12056,HCPCS,Outpatient,,,339,339,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,247.47,73,,197.976,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,237.3,70,,189.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.05,19.19,,52.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,169.5,50,,135.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.05,1319.85,
INTMD RPR FACE/MM 20.1-30CM,82012056,CDM,510,RC,13121,HCPCS,Outpatient,,,429,429,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,313.17,73,,250.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,300.3,70,,240.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.33,19.19,,65.864,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.5,50,,171.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.33,1319.85,
"REPAIR, COMPLEX, SCALP/ARM/LEG 2.6-7.5CM",82013121,CDM,510,RC,20551,HCPCS,Outpatient,,,298,298,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,217.54,73,,174.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,208.6,70,,166.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.19,19.19,,45.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149,50,,119.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.19,1508.85,
Injection of medication into the tendon/ligament origin,82020551,CDM,510,RC,20605,HCPCS,Outpatient,,,37,37,,,,,,Other,Not Separately Reimbursable,30.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,30.53,82.5,,24.424,percent of total billed charges,Pays at 82.5% of total Billed charges,27.01,73,,21.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.9,70,,20.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,19.19,,5.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.5,50,,14.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,30.53,
Draining or injecting medication into a large joint/bursa without ultrasound,82020605,CDM,510,RC,21014,HCPCS,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
EXCIS SOFT TISS TUMOR FACE/SCALP 2CM OR>,82021014,CDM,510,RC,30100,HCPCS,Outpatient,,,583,583,,,,,,Other,Not Separately Reimbursable,480.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,480.98,82.5,,384.784,percent of total billed charges,Pays at 82.5% of total Billed charges,425.59,73,,340.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,408.1,70,,326.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.88,19.19,,89.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,291.5,50,,233.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.88,480.98,
"BIOPSY, INTRANASAL",82030100,CDM,510,RC,30300,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
"REMOVAL OF FOREIGN BODY, INTRANASAL",82030300,CDM,510,RC,30903,HCPCS,Outpatient,,,114,114,,,,,,Other,Not Separately Reimbursable,94.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,94.05,82.5,,75.24,percent of total billed charges,Pays at 82.5% of total Billed charges,83.22,73,,66.576,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.8,70,,63.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.88,19.19,,17.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57,50,,45.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.88,94.05,
CONTROL NASAL HEM/COMPLEX,82030903,CDM,510,RC,31231,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,64.24,73,,51.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,70,,49.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,19.19,,13.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44,50,,35.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,982.8,
"Nasal endoscopy, diagnostic, unilateral or bilateral",82031231,CDM,510,RC,31505,HCPCS,Outpatient,,,72,72,,,,,,Other,Not Separately Reimbursable,59.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,59.4,82.5,,47.52,percent of total billed charges,Pays at 82.5% of total Billed charges,52.56,73,,42.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,50.4,70,,40.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,19.19,,11.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36,50,,28.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.82,59.4,
LARYNOSCOPY THROAT,82031505,CDM,510,RC,31575,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,43.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,43.73,82.5,,34.984,percent of total billed charges,Pays at 82.5% of total Billed charges,38.69,73,,30.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.1,70,,29.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,19.19,,8.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.5,50,,21.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,43.73,
"Flexible, fiberoptic diagnostic laryngoscopy",82031575,CDM,510,RC,40510,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
PARTIAL EXCISION OF LIP,82040510,CDM,510,RC,40808,HCPCS,Outpatient,,,394,394,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,287.62,73,,230.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,275.8,70,,220.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75.61,19.19,,60.488,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,197,50,,157.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75.61,1319.85,
"BIOPSY, VESTIBULE OF MOUTH",82040808,CDM,510,RC,40810,HCPCS,Outpatient,,,119,119,,,,,,Other,Not Separately Reimbursable,98.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,98.18,82.5,,78.544,percent of total billed charges,Pays at 82.5% of total Billed charges,86.87,73,,69.496,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,83.3,70,,66.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.84,19.19,,18.272,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,50,,47.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.84,98.18,
EXC OF LESION MUCOSA/SUBMUCOSA W/O RPR,82040810,CDM,510,RC,40812,HCPCS,Outpatient,,,141,141,,,,,,Other,Not Separately Reimbursable,116.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,116.33,82.5,,93.064,percent of total billed charges,Pays at 82.5% of total Billed charges,102.93,73,,82.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.7,70,,78.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,19.19,,21.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.5,50,,56.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,116.33,
EXC OF LESION MUCOSA/SUBMUCOSA W SIM RPR,82040812,CDM,510,RC,42300,HCPCS,Outpatient,,,219,219,,,,,,Other,Not Separately Reimbursable,180.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,180.68,82.5,,144.544,percent of total billed charges,Pays at 82.5% of total Billed charges,159.87,73,,127.896,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153.3,70,,122.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.03,19.19,,33.624,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.5,50,,87.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.03,180.68,
"DRAINAGE OF ABSCESS; PAROTID, SIMPLE",82042300,CDM,510,RC,42330,HCPCS,Outpatient,,,168,168,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,122.64,73,,98.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.6,70,,94.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.24,19.19,,25.792,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,50,,67.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.24,982.8,
SIALOLITHOTOMY; PAROTID UNCOMP INTRAORAL,82042330,CDM,510,RC,42800,HCPCS,Outpatient,,,182,182,,,,,,Other,Not Separately Reimbursable,150.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,150.15,82.5,,120.12,percent of total billed charges,Pays at 82.5% of total Billed charges,132.86,73,,106.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,127.4,70,,101.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.93,19.19,,27.944,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,50,,72.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.93,150.15,
BIOPSY: OROPHARYNX,82042800,CDM,510,RC,60300,HCPCS,Outpatient,,,126,126,,,,,,Other,Not Separately Reimbursable,103.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,103.95,82.5,,83.16,percent of total billed charges,Pays at 82.5% of total Billed charges,91.98,73,,73.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,88.2,70,,70.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.18,19.19,,19.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63,50,,50.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.18,103.95,
"ASPIRATION/INJECTION, THYROID CYST",82060300,CDM,510,RC,69005,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
"DRAINAGE EXT EAR, ABSCESS/HEMATOMA; COMP",82069005,CDM,510,RC,69100,HCPCS,Outpatient,,,171,171,,,,,,Other,Not Separately Reimbursable,141.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,141.08,82.5,,112.864,percent of total billed charges,Pays at 82.5% of total Billed charges,124.83,73,,99.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,119.7,70,,95.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.81,19.19,,26.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85.5,50,,68.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.81,141.08,
BIOPSY EXTERNAL EAR,82069100,CDM,510,RC,69200,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
REMOVE FOREIGN BODY EAR,82069200,CDM,510,RC,69210,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
Removal of ear wax from one or both ears,82069210,CDM,510,RC,69220,HCPCS,Outpatient,,,6,6,,,,,,Other,Not Separately Reimbursable,4.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.95,82.5,,3.96,percent of total billed charges,Pays at 82.5% of total Billed charges,4.38,73,,3.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.2,70,,3.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,19.19,,0.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3,50,,2.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.15,4.95,
"DEBRIDEMENT, MASTOIDECTOMY CAVITY, SIMPL",82069220,CDM,510,RC,69222,HCPCS,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,47.03,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.03,82.5,,37.624,percent of total billed charges,Pays at 82.5% of total Billed charges,41.61,73,,33.288,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.9,70,,31.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,19.19,,8.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.5,50,,22.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.94,47.03,
"DEBRIDEMENT, MASTOIDECTOMY CAVITY, COMPL",82069222,CDM,510,RC,69420,HCPCS,Outpatient,,,147,147,,,,,,Other,Not Separately Reimbursable,121.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,121.28,82.5,,97.024,percent of total billed charges,Pays at 82.5% of total Billed charges,107.31,73,,85.848,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.9,70,,82.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.21,19.19,,22.568,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.5,50,,58.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.21,121.28,
MYRINGOTOMY,82069420,CDM,510,RC,69433,HCPCS,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,107.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,107.25,82.5,,85.8,percent of total billed charges,Pays at 82.5% of total Billed charges,94.9,73,,75.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91,70,,72.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,19.19,,19.96,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65,50,,52,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.95,107.25,
"TYMPANOSTOMY, LOCAL/TOPICAL ANESTHESIA",82069433,CDM,510,RC,69610,HCPCS,Outpatient,,,143,143,,,,,,Other,Not Separately Reimbursable,117.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,117.98,82.5,,94.384,percent of total billed charges,Pays at 82.5% of total Billed charges,104.39,73,,83.512,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,100.1,70,,80.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.44,19.19,,21.952,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.5,50,,57.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.44,117.98,
TYMPANIC MEMBRANE RPR W OR W/O SITE PREP,82069610,CDM,510,RC,69620,HCPCS,Outpatient,,,319,319,,,,,,Other,Not Separately Reimbursable,263.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,263.18,82.5,,210.544,percent of total billed charges,Pays at 82.5% of total Billed charges,232.87,73,,186.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,223.3,70,,178.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.22,19.19,,48.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,159.5,50,,127.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.22,263.18,
MYRINGOPLASTY,82069620,CDM,510,RC,87880,HCPCS,Outpatient,,,530,530,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,386.9,73,,309.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,371,70,,296.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,19.19,,81.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,265,50,,212,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,101.71,1319.85,
Test for strep A,82087880,CDM,306,RC,92511,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,72.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,72.6,82.5,,58.08,percent of total billed charges,Pays at 82.5% of total Billed charges,64.24,73,,51.392,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,70,,49.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,19.19,,13.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44,50,,35.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.89,72.6,
NASOPHARYNGOSCOPY W/ENDOSCOPE,82092511,CDM,510,RC,92552,HCPCS,Outpatient,,,41,41,,,,,,Other,Not Separately Reimbursable,33.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,33.83,82.5,,27.064,percent of total billed charges,Pays at 82.5% of total Billed charges,29.93,73,,23.944,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.7,70,,22.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,19.19,,6.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.5,50,,16.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.87,33.83,
Type of hearing test,82092552,CDM,510,RC,92567,HCPCS,Outpatient,,,206,206,,,,,,Other,Not Separately Reimbursable,115.04,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,115.04,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,150.38,73,,120.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,144.2,70,,115.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.53,19.19,,31.624,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,103,50,,82.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.53,150.38,
TYMPANOMETRY,82092567,CDM,510,RC,95115,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,141.37,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,141.37,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,8.76,73,,7.008,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.4,70,,6.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,19.19,,1.84,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6,50,,4.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.3,141.37,
Allergy shot-1 shot,82095115,CDM,510,RC,95117,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,48.68,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,48.68,82.5,,38.944,percent of total billed charges,Pays at 82.5% of total Billed charges,43.07,73,,34.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41.3,70,,33.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,19.19,,9.056,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.5,50,,23.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.32,48.68,
Multiple allergy shots,82095117,CDM,510,RC,96372,HCPCS,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,25.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,25.58,82.5,,20.464,percent of total billed charges,Pays at 82.5% of total Billed charges,22.63,73,,18.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.7,70,,17.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,19.19,,4.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.5,50,,12.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,25.58,
INJECTION ADMINISTRATION,82096372,CDM,510,RC,99201,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
OFFICE VISIT 10 MIN NEW,82099201,CDM,510,RC,99202,HCPCS,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,23.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.93,82.5,,19.144,percent of total billed charges,Pays at 82.5% of total Billed charges,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,23.93,
"New patient office or other outpatient visit, typically 10 minutes",82099202,CDM,510,RC,99203,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
"New patient office or other outpatient visit, typically 30 min",82099203,CDM,510,RC,99204,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,69.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,69.3,82.5,,55.44,percent of total billed charges,Pays at 82.5% of total Billed charges,61.32,73,,49.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.8,70,,47.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,19.19,,12.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,50,,33.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,69.3,
"New patient office of other outpatient visit, typically 45 min",82099204,CDM,510,RC,99205,HCPCS,Outpatient,,,141,141,,,,,,Other,Not Separately Reimbursable,116.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,116.33,82.5,,93.064,percent of total billed charges,Pays at 82.5% of total Billed charges,102.93,73,,82.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.7,70,,78.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,19.19,,21.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.5,50,,56.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,116.33,
"New patient office of other outpatient visit, typically 60 min",82099205,CDM,510,RC,99211,HCPCS,Outpatient,,,161,161,,,,,,Other,Not Separately Reimbursable,132.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132.83,82.5,,106.264,percent of total billed charges,Pays at 82.5% of total Billed charges,117.53,73,,94.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112.7,70,,90.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.9,19.19,,24.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.5,50,,64.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.9,132.83,
Outpatient visit of established patient not requiring a physician,82099211,CDM,510,RC,99212,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
Outpatient visit of established patient requiring a physician,82099212,CDM,510,RC,99213,HCPCS,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,23.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.1,82.5,,18.48,percent of total billed charges,Pays at 82.5% of total Billed charges,20.44,73,,16.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.6,70,,15.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,19.19,,4.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,50,,11.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,23.1,
"Established patient office or other outpatient visit, typically 15 minutes",82099213,CDM,510,RC,99214,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
"Established patient office or other outpatient visit, typically 25 minutes",82099214,CDM,510,RC,99215,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
"Established patient office or other outpatient, visit typically 40 minutes",82099215,CDM,510,RC,99201,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
OFFICE VISIT 10 MIN NEW,82199201,CDM,510,RC,99202,HCPCS,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,23.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.93,82.5,,19.144,percent of total billed charges,Pays at 82.5% of total Billed charges,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,23.93,
OFFICE VISIT 20 MIN NEW,82199202,CDM,510,RC,99203,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
OFFICE VISIT 30 MIN NEW,82199203,CDM,510,RC,99204,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,69.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,69.3,82.5,,55.44,percent of total billed charges,Pays at 82.5% of total Billed charges,61.32,73,,49.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.8,70,,47.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,19.19,,12.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,50,,33.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,69.3,
OFFICE VISIT 45 MIN NEW,82199204,CDM,510,RC,99205,HCPCS,Outpatient,,,141,141,,,,,,Other,Not Separately Reimbursable,116.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,116.33,82.5,,93.064,percent of total billed charges,Pays at 82.5% of total Billed charges,102.93,73,,82.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.7,70,,78.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,19.19,,21.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,70.5,50,,56.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.06,116.33,
OFFICE VISIT 60 MIN NEW,82199205,CDM,510,RC,99211,HCPCS,Outpatient,,,161,161,,,,,,Other,Not Separately Reimbursable,132.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,132.83,82.5,,106.264,percent of total billed charges,Pays at 82.5% of total Billed charges,117.53,73,,94.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,112.7,70,,90.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.9,19.19,,24.72,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,80.5,50,,64.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.9,132.83,
OFFICE VISIT 5 MIN EST,82199211,CDM,510,RC,99212,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
OFFICE VISIT 10 MIN EST,82199212,CDM,510,RC,99213,HCPCS,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,23.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.1,82.5,,18.48,percent of total billed charges,Pays at 82.5% of total Billed charges,20.44,73,,16.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.6,70,,15.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,19.19,,4.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,50,,11.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,23.1,
OFFICE VISIT 15 MIN EST,82199213,CDM,510,RC,99214,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
OFFICE VISIT 25 MIN EST,82199214,CDM,510,RC,99215,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
OFFICE VISIT 40 MIN EST,82199215,CDM,510,RC,85610,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
PT/INR,89085610,CDM,300,RC,G0008,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,37.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.95,82.5,,30.36,percent of total billed charges,Pays at 82.5% of total Billed charges,33.58,73,,26.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.2,70,,25.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,19.19,,7.064,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23,50,,18.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.83,37.95,
FLU VACCINE ADMINISTRATION,95000008,CDM,771,RC,G0009,HCPCS,Outpatient,,,5,5,,,,,,Other,Not Separately Reimbursable,4.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,4.13,82.5,,3.304,percent of total billed charges,Pays at 82.5% of total Billed charges,3.65,73,,2.92,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,70,,2.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,19.19,,0.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,0.96,4.13,
AMINISTRATION OF PNEUMOCOCCAL VACCINE,95000009,CDM,771,RC,S0020,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
BUPIVICAINE HCl PER 30ML,95000020,CDM,510,RC,Q0091,HCPCS,Outpatient,,,37,37,,,,,,Other,Not Separately Reimbursable,30.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,30.53,82.5,,24.424,percent of total billed charges,Pays at 82.5% of total Billed charges,27.01,73,,21.608,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.9,70,,20.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,19.19,,5.68,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.5,50,,14.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.1,30.53,
PAP SMEAR COLLECTION,95000091,CDM,510,RC,G0101,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
PELVIC AND BREAST SCREENING EXAM,95000101,CDM,510,RC,G0102,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
Prostate cancer screening; digital rectal examination,95000102,CDM,510,RC,J2550,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
PHENERGAN/PROMETHAZINE UP TO 50 MG,95000255,CDM,510,RC,G0511,HCPCS,Outpatient,,,23,23,,,,,,Other,Not Separately Reimbursable,18.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,82.5,,15.184,percent of total billed charges,Pays at 82.5% of total Billed charges,16.79,73,,13.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.1,70,,12.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,19.19,,3.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.5,50,,9.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.41,18.98,
"CHRONIC CARE MGMT SVC, 20 MIN",95000511,CDM,510,RC,J0696,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,28.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.88,82.5,,23.104,percent of total billed charges,Pays at 82.5% of total Billed charges,25.55,73,,20.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,70,,19.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,19.19,,5.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,50,,14,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,28.88,
ROCEPHIN IM (CEFTRIAXONE) INJ: 250MG,95000696,CDM,636,RC,J0702,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,43.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,43.73,82.5,,34.984,percent of total billed charges,Pays at 82.5% of total Billed charges,38.69,73,,30.952,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.1,70,,29.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,19.19,,8.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.5,50,,21.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.17,43.73,
Injection to treat reaction to a drug,95000702,CDM,636,RC,J1030,HCPCS,Outpatient,,,212,212,,,,,,Other,Not Separately Reimbursable,174.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,174.9,82.5,,139.92,percent of total billed charges,Pays at 82.5% of total Billed charges,154.76,73,,123.808,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.4,70,,118.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.68,19.19,,32.544,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,106,50,,84.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.68,174.9,
DEPO-MEDROL INJECTION PER 40MG,95001030,CDM,636,RC,J1885,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
TORADOL INJECTION PER 15MG,95001885,CDM,250,RC,J2405,HCPCS,Outpatient,,,43,43,,,,,,Other,Not Separately Reimbursable,35.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,35.48,82.5,,28.384,percent of total billed charges,Pays at 82.5% of total Billed charges,31.39,73,,25.112,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.1,70,,24.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,19.19,,6.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.5,50,,17.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.25,35.48,
ONDANSETRON(ZOFRAN)INJ:4MG,95002405,CDM,636,RC,J2930,HCPCS,Outpatient,,,333,333,,,,,,Other,Not Separately Reimbursable,274.73,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,274.73,82.5,,219.784,percent of total billed charges,Pays at 82.5% of total Billed charges,243.09,73,,194.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,233.1,70,,186.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.9,19.19,,51.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,166.5,50,,133.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,63.9,274.73,
methylPREDNISOLONE(SoluMEDROL)INJ:125MG,95002930,CDM,510,RC,J3301,HCPCS,Outpatient,,,15,15,,,,,,Other,Not Separately Reimbursable,12.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,12.38,82.5,,9.904,percent of total billed charges,Pays at 82.5% of total Billed charges,10.95,73,,8.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,70,,8.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,19.19,,2.304,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.5,50,,6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.88,12.38,
KENALOG 10 MG INJ,95003301,CDM,636,RC,J3420,HCPCS,Outpatient,,,21,21,,,,,,Other,Not Separately Reimbursable,17.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,17.33,82.5,,13.864,percent of total billed charges,Pays at 82.5% of total Billed charges,15.33,73,,12.264,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.7,70,,11.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,19.19,,3.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,50,,8.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.03,17.33,
B-12 INJECTION UP TO 1000MCG,95003420,CDM,250,RC,10060,HCPCS,Outpatient,,,16,16,,,,,,Other,Not Separately Reimbursable,13.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,13.2,82.5,,10.56,percent of total billed charges,Pays at 82.5% of total Billed charges,11.68,73,,9.344,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.2,70,,8.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,19.19,,2.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8,50,,6.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.07,13.2,
Incision and drainage of abscess; simple or single and complex or multiple,95010060,CDM,510,RC,10061,HCPCS,Outpatient,,,106,106,,,,,,Other,Not Separately Reimbursable,87.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,87.45,82.5,,69.96,percent of total billed charges,Pays at 82.5% of total Billed charges,77.38,73,,61.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.2,70,,59.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.34,19.19,,16.272,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53,50,,42.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.34,87.45,
I&D ABCESS COMPLICATED OR MULTIPLE,95010061,CDM,510,RC,10120,HCPCS,Outpatient,,,197,197,,,,,,Other,Not Separately Reimbursable,162.53,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,162.53,82.5,,130.024,percent of total billed charges,Pays at 82.5% of total Billed charges,143.81,73,,115.048,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,137.9,70,,110.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,19.19,,30.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,98.5,50,,78.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,162.53,
I&D REMOVE FB SIMPLE,95010120,CDM,510,RC,10121,HCPCS,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,93.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,93.23,82.5,,74.584,percent of total billed charges,Pays at 82.5% of total Billed charges,82.49,73,,65.992,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,79.1,70,,63.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,19.19,,17.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.5,50,,45.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.68,93.23,
I&D REMOVE FB COMPLEX,95010121,CDM,510,RC,10160,HCPCS,Outpatient,,,205,205,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,149.65,73,,119.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,143.5,70,,114.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,19.19,,31.472,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.5,50,,82,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.34,1319.85,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",95010160,CDM,510,RC,11200,HCPCS,Outpatient,,,105,105,,,,,,Other,Not Separately Reimbursable,86.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,86.63,82.5,,69.304,percent of total billed charges,Pays at 82.5% of total Billed charges,76.65,73,,61.32,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.5,70,,58.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,19.19,,16.12,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,50,,42,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.15,86.63,
"Removal of skin tags, multiple fibrocutaneous tags, any area",95011200,CDM,510,RC,11403,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,66.83,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66.83,82.5,,53.464,percent of total billed charges,Pays at 82.5% of total Billed charges,59.13,73,,47.304,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56.7,70,,45.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,19.19,,12.432,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.5,50,,32.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.54,66.83,
EXC-BENIGN TRUCK/ARM/LEGS 2. 1-3.0 CM,95011403,CDM,510,RC,11730,HCPCS,Outpatient,,,163,163,,,,,,Other,Not Separately Reimbursable,134.48,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,134.48,82.5,,107.584,percent of total billed charges,Pays at 82.5% of total Billed charges,118.99,73,,95.192,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,114.1,70,,91.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.28,19.19,,25.024,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,81.5,50,,65.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.28,134.48,
Separation and removal of the entire nail plate or a portion of nail plate,95011730,CDM,510,RC,11740,HCPCS,Outpatient,,,61,61,,,,,,Other,Not Separately Reimbursable,50.33,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,50.33,82.5,,40.264,percent of total billed charges,Pays at 82.5% of total Billed charges,44.53,73,,35.624,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.7,70,,34.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,19.19,,9.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.5,50,,24.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.71,50.33,
EVACUATION OF SUBUNGAL HEMATOMA,95011740,CDM,510,RC,11760,HCPCS,Outpatient,,,36,36,,,,,,Other,Not Separately Reimbursable,29.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,29.7,82.5,,23.76,percent of total billed charges,Pays at 82.5% of total Billed charges,26.28,73,,21.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.2,70,,20.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,19.19,,5.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18,50,,14.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,29.7,
REPAIR OF NAIL BED,95011760,CDM,510,RC,11900,HCPCS,Outpatient,,,125,125,,,,,,Other,Not Separately Reimbursable,103.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,103.13,82.5,,82.504,percent of total billed charges,Pays at 82.5% of total Billed charges,91.25,73,,73,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.5,70,,70,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,19.19,,19.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,62.5,50,,50,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.99,103.13,
Injections to remove up to 7 lesions on the skin,95011900,CDM,510,RC,11901,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,28.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.88,82.5,,23.104,percent of total billed charges,Pays at 82.5% of total Billed charges,25.55,73,,20.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,70,,19.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,19.19,,5.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,50,,14,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,28.88,
ADDED SKIN LESIONS INJECTION,95011901,CDM,510,RC,12004,HCPCS,Outpatient,,,54,54,,,,,,Other,Not Separately Reimbursable,44.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,44.55,82.5,,35.64,percent of total billed charges,Pays at 82.5% of total Billed charges,39.42,73,,31.536,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.8,70,,30.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,19.19,,8.288,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27,50,,21.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.36,44.55,
REPAIR SUPERFICAL WOUND 7.6-12.5CM,95012004,CDM,510,RC,12005,HCPCS,Outpatient,,,82,82,,,,,,Other,Not Separately Reimbursable,67.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,67.65,82.5,,54.12,percent of total billed charges,Pays at 82.5% of total Billed charges,59.86,73,,47.888,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.4,70,,45.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,19.19,,12.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,41,50,,32.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.74,67.65,
REPAIR SUPERFICAL WOUND 12.6-20CM,95012005,CDM,510,RC,12006,HCPCS,Outpatient,,,106,106,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,77.38,73,,61.904,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.2,70,,59.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.34,19.19,,16.272,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53,50,,42.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.34,1319.85,
REPAIR SUPERFICAL WOUND 20.1-30CM,95012006,CDM,510,RC,12007,HCPCS,Outpatient,,,131,131,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,95.63,73,,76.504,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,91.7,70,,73.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.14,19.19,,20.112,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,65.5,50,,52.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.14,1319.85,
REPAIR SUPERFICAL WOUND >30CM,95012007,CDM,510,RC,13121,HCPCS,Outpatient,,,165,165,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,120.45,73,,96.36,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,115.5,70,,92.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.66,19.19,,25.328,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.5,50,,66,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.66,1319.85,
REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5CM,95013121,CDM,510,RC,17000,HCPCS,Outpatient,,,298,298,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,217.54,73,,174.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,208.6,70,,166.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.19,19.19,,45.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,149,50,,119.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,57.19,1508.85,
Destruction of pre-cancerous lesion,95017000,CDM,510,RC,20526,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,47.85,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,47.85,82.5,,38.28,percent of total billed charges,Pays at 82.5% of total Billed charges,42.34,73,,33.872,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.6,70,,32.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,19.19,,8.904,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29,50,,23.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.13,47.85,
"INJECTION, THERAPEUTIC, CARPAL TUNNEL",95020526,CDM,510,RC,20550,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,53.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,53.63,82.5,,42.904,percent of total billed charges,Pays at 82.5% of total Billed charges,47.45,73,,37.96,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.5,70,,36.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,19.19,,9.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.5,50,,26,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.47,53.63,
Injection of medication into a tendon or ligament,95020550,CDM,510,RC,20551,HCPCS,Outpatient,,,44,44,,,,,,Other,Not Separately Reimbursable,36.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,36.3,82.5,,29.04,percent of total billed charges,Pays at 82.5% of total Billed charges,32.12,73,,25.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.8,70,,24.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,19.19,,6.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22,50,,17.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,36.3,
Injection of medication into the tendon/ligament origin,95020551,CDM,510,RC,20552,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
INJ TRIGGER POINT 1/2 MUSCL,95020552,CDM,510,RC,20553,HCPCS,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
Injection of medication into an area that triggers pain,95020553,CDM,510,RC,20600,HCPCS,Outpatient,,,48,48,,,,,,Other,Not Separately Reimbursable,39.6,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,39.6,82.5,,31.68,percent of total billed charges,Pays at 82.5% of total Billed charges,35.04,73,,28.032,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.6,70,,26.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,19.19,,7.368,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24,50,,19.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.21,39.6,
Draining or injecting medication into a small joint/bursa without ultrasound,95020600,CDM,510,RC,20604,HCPCS,Outpatient,,,39,39,,,,,,Other,Not Separately Reimbursable,32.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,32.18,82.5,,25.744,percent of total billed charges,Pays at 82.5% of total Billed charges,28.47,73,,22.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.3,70,,21.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,19.19,,5.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.5,50,,15.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,32.18,
ARTHROCESPIRATION/INJ;SM JNT/BUR W/US,95020604,CDM,510,RC,20605,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
Draining or injecting medication into a large joint/bursa without ultrasound,95020605,CDM,510,RC,20606,HCPCS,Outpatient,,,42,42,,,,,,Other,Not Separately Reimbursable,34.65,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,34.65,82.5,,27.72,percent of total billed charges,Pays at 82.5% of total Billed charges,30.66,73,,24.528,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.4,70,,23.52,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,19.19,,6.448,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,50,,16.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.06,34.65,
ARTHROCESPIRA/INJ; INTER JNT/BUR W/US,95020606,CDM,510,RC,20610,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,49.5,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,49.5,82.5,,39.6,percent of total billed charges,Pays at 82.5% of total Billed charges,43.8,73,,35.04,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,70,,33.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,19.19,,9.208,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30,50,,24,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,11.51,49.5,
Draining or injecting medication into a major joint/bursa without ultrasound,95020610,CDM,510,RC,20611,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
ARTHROCESPIRA/INJ; MAJ JNT/BUR W/US,95020611,CDM,510,RC,20612,HCPCS,Outpatient,,,68,68,,,,,,Other,Not Separately Reimbursable,56.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.1,82.5,,44.88,percent of total billed charges,Pays at 82.5% of total Billed charges,49.64,73,,39.712,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,47.6,70,,38.08,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,19.19,,10.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34,50,,27.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.05,56.1,
Removal of fluid or injection of medication into a ganglion cyst,95020612,CDM,510,RC,21014,HCPCS,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,38.78,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,38.78,82.5,,31.024,percent of total billed charges,Pays at 82.5% of total Billed charges,34.31,73,,27.448,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32.9,70,,26.32,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,19.19,,7.216,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.5,50,,18.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.02,38.78,
EXCIS SFT TISS TUMOR FACE/SCALP 2CM OR >,95021014,CDM,510,RC,25111,HCPCS,Outpatient,,,583,583,,,,,,Other,Not Separately Reimbursable,480.98,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,480.98,82.5,,384.784,percent of total billed charges,Pays at 82.5% of total Billed charges,425.59,73,,340.472,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,408.1,70,,326.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.88,19.19,,89.504,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,291.5,50,,233.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,111.88,480.98,
EXCISION OF GANGLION CYST,95025111,CDM,510,RC,25505,HCPCS,Outpatient,,,354,354,,,,,,Other,Not Separately Reimbursable,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1508.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,258.42,73,,206.736,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,247.8,70,,198.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,19.19,,54.344,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,177,50,,141.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,67.93,1508.85,
CLSD TRMT OF RADIAL SHAFT FX;W/MANIP,95025505,CDM,510,RC,25609,HCPCS,Outpatient,,,501,501,,,,,,Other,Not Separately Reimbursable,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,982.8,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,365.73,73,,292.584,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,350.7,70,,280.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.14,19.19,,76.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,250.5,50,,200.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,96.14,982.8,
ORIF LEFT WRIST,95025609,CDM,510,RC,26210,HCPCS,Outpatient,,,1171,1171,,,,,,Other,Not Separately Reimbursable,2123.1,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,2123.1,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,854.83,73,,683.864,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,819.7,70,,655.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,224.71,19.19,,179.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,585.5,50,,468.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,224.71,2123.1,
EXC BONE CYST/TUMOR OF FINGER,95026210,CDM,510,RC,26546,HCPCS,Outpatient,,,490,490,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,357.7,73,,286.16,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,343,70,,274.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.03,19.19,,75.224,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,245,50,,196,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.03,1319.85,
"REPAIR NON UNION, METACARPAL OR PHALANX",95026546,CDM,510,RC,26605,HCPCS,Outpatient,,,1084,1084,,,,,,Other,Not Separately Reimbursable,1861.65,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1861.65,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,791.32,73,,633.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,758.8,70,,607.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,208.02,19.19,,166.416,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,542,50,,433.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,208.02,1861.65,
CLSD TRMT OF METACARPAL FX W/MANIPULATIO,95026605,CDM,510,RC,26615,HCPCS,Outpatient,,,321,321,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,234.33,73,,187.464,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,224.7,70,,179.76,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,19.19,,49.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,160.5,50,,128.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,61.6,1319.85,
ORIF 5TH METACARPAL,95026615,CDM,510,RC,27372,HCPCS,Outpatient,,,640,640,,,,,,Other,Not Separately Reimbursable,1861.65,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1861.65,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,467.2,73,,373.76,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,448,70,,358.4,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.82,19.19,,98.256,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,320,50,,256,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,122.82,1861.65,
EXCISION FOREIGN BODY LEFT KNEE,95027372,CDM,510,RC,29065,HCPCS,Outpatient,,,444,444,,,,,,Other,Not Separately Reimbursable,2945.25,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,2945.25,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,324.12,73,,259.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,310.8,70,,248.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85.2,19.19,,68.16,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,222,50,,177.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,85.2,2945.25,
APPLICATION OF LONG ARM CAST,95029065,CDM,510,RC,29075,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,62.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,62.7,82.5,,50.16,percent of total billed charges,Pays at 82.5% of total Billed charges,55.48,73,,44.384,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,53.2,70,,42.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,19.19,,11.664,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38,50,,30.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.58,62.7,
APPLICATION OF FOREARM CAST,95029075,CDM,510,RC,29085,HCPCS,Outpatient,,,69,69,,,,,,Other,Not Separately Reimbursable,56.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,56.93,82.5,,45.544,percent of total billed charges,Pays at 82.5% of total Billed charges,50.37,73,,40.296,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,48.3,70,,38.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.24,19.19,,10.592,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,50,,27.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.24,56.93,
APPLICATION OF HAND/WRIST CAST,95029085,CDM,510,RC,29105,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
APPLICATION OF LONG ARM SPLINT,95029105,CDM,510,RC,29125,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,54.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,54.45,82.5,,43.56,percent of total billed charges,Pays at 82.5% of total Billed charges,48.18,73,,38.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.2,70,,36.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,19.19,,10.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33,50,,26.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,54.45,
APPLICATION OF FOREARM SPLINT,95029125,CDM,510,RC,29130,HCPCS,Outpatient,,,44,44,,,,,,Other,Not Separately Reimbursable,36.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,36.3,82.5,,29.04,percent of total billed charges,Pays at 82.5% of total Billed charges,32.12,73,,25.696,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.8,70,,24.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,19.19,,6.752,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22,50,,17.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.44,36.3,
APPLICATION OF FINGER SPLINT,95029130,CDM,510,RC,29345,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,26.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,26.4,82.5,,21.12,percent of total billed charges,Pays at 82.5% of total Billed charges,23.36,73,,18.688,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.4,70,,17.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,19.19,,4.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16,50,,12.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.14,26.4,
APPL OF SHORT LEG CAST (THIGH-TOES),95029345,CDM,510,RC,29405,HCPCS,Outpatient,,,112,112,,,,,,Other,Not Separately Reimbursable,92.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,92.4,82.5,,73.92,percent of total billed charges,Pays at 82.5% of total Billed charges,81.76,73,,65.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.4,70,,62.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,19.19,,17.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,50,,44.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,92.4,
APPL OF SHORT LEG CAST BELOW KNEE TO TOE,95029405,CDM,510,RC,29505,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,54.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,54.45,82.5,,43.56,percent of total billed charges,Pays at 82.5% of total Billed charges,48.18,73,,38.544,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.2,70,,36.96,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,19.19,,10.136,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33,50,,26.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.67,54.45,
APPLICATION OF LONG LEG SPLINT,95029505,CDM,510,RC,29515,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
APPLICATION OF LOWER LEG SPLINT,95029515,CDM,510,RC,36415,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
Collection of venous blood by venipuncture,95036415,CDM,510,RC,64721,HCPCS,Outpatient,,,7,7,,,,,,Other,Not Separately Reimbursable,9.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,9.45,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,5.11,73,,4.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.9,70,,3.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,19.19,,1.072,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.5,50,,2.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.34,9.45,
Release of the transverse carpal ligament,95064721,CDM,510,RC,69200,HCPCS,Outpatient,,,474,474,,,,,,Other,Not Separately Reimbursable,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,1319.85,315,,,fee schedule,Pays at 315% of BCBS ASC fee schedule for outpatient setting,346.02,73,,276.816,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,331.8,70,,265.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.96,19.19,,72.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,237,50,,189.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.96,1319.85,
REM FOREIGN BODY FROM EXT AUDITORY CANAL,95069200,CDM,510,RC,69210,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,42.9,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,42.9,82.5,,34.32,percent of total billed charges,Pays at 82.5% of total Billed charges,37.96,73,,30.368,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.4,70,,29.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,19.19,,7.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26,50,,20.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.98,42.9,
Removal of ear wax from one or both ears,95069210,CDM,510,RC,80305,HCPCS,Outpatient,,,36,36,,,,,,Other,Not Separately Reimbursable,29.7,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,29.7,82.5,,23.76,percent of total billed charges,Pays at 82.5% of total Billed charges,26.28,73,,21.024,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,25.2,70,,20.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,19.19,,5.528,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18,50,,14.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.91,29.7,
"DRUG SCREEN, PRESUMPTIVE, BY DIRECT OPTI",95080305,CDM,510,RC,81002,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,61.68,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,61.68,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,25.55,73,,20.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,70,,19.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,19.19,,5.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,50,,14,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,61.68,
Manual urinalysis test with examination without using microscope,95081002,CDM,307,RC,81025,HCPCS,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,11.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,11.43,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,11.43,
Urine pregnancy test,95081025,CDM,307,RC,82272,HCPCS,Outpatient,,,9,9,,,,,,Other,Not Separately Reimbursable,28.29,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,28.29,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,6.57,73,,5.256,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.3,70,,5.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,19.19,,1.384,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.5,50,,3.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.73,28.29,
"BLOOD OCCULT (GUAIAC) QUALIT, FECES 1-3",95082272,CDM,510,RC,82962,HCPCS,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,9.08,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,9.08,82.5,,7.264,percent of total billed charges,Pays at 82.5% of total Billed charges,8.03,73,,6.424,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.7,70,,6.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,19.19,,1.688,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.5,50,,4.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.11,9.08,
GLUCOSE FINGER,95082962,CDM,300,RC,83036,HCPCS,Outpatient,,,8,8,,,,,,Other,Not Separately Reimbursable,14.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,14.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,5.84,73,,4.672,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.6,70,,4.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,19.19,,1.232,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4,50,,3.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.54,14.14,
A1C GLYCOSYLATED,95083036,CDM,510,RC,85610,HCPCS,Outpatient,,,27,27,,,,,,Other,Not Separately Reimbursable,22.28,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,22.28,82.5,,17.824,percent of total billed charges,Pays at 82.5% of total Billed charges,19.71,73,,15.768,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.9,70,,15.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,19.19,,4.144,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.5,50,,10.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.18,22.28,
"Blood test, clotting time",95085610,CDM,510,RC,87210,HCPCS,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,17.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,17.58,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,9.49,73,,7.592,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.1,70,,7.28,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,19.19,,1.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.5,50,,5.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.49,17.58,
A lab test to screen for evidence of vaginal infection,95087210,CDM,510,RC,87804,HCPCS,Outpatient,,,14,14,,,,,,Other,Not Separately Reimbursable,19.09,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,19.09,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,10.22,73,,8.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.8,70,,7.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.19,,2.152,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,50,,5.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,2.69,19.09,
INFLUENZA A RAPID TEST (QUICKVUE),95087804,CDM,302,RC,87880,HCPCS,Outpatient,,,39,39,,,,,,Other,Not Separately Reimbursable,32.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,32.18,82.5,,25.744,percent of total billed charges,Pays at 82.5% of total Billed charges,28.47,73,,22.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.3,70,,21.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,19.19,,5.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.5,50,,15.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,32.18,
Test for strep A,95087880,CDM,306,RC,90471,HCPCS,Outpatient,,,39,39,,,,,,Other,Not Separately Reimbursable,32.18,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,32.18,82.5,,25.744,percent of total billed charges,Pays at 82.5% of total Billed charges,28.47,73,,22.776,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.3,70,,21.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,19.19,,5.984,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.5,50,,15.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7.48,32.18,
Immunization administration by a medical assistant or nurse,95090471,CDM,771,RC,90656,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
Flu shot-high dose for 2019-2020 flu season given by injection,95090656,CDM,636,RC,90662,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
FLU(HIGH DOSE>65 YO)VACCINE:0.5ML,95090662,CDM,636,RC,90670,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
PREVNAR-13(PNEUMOCOCCAL)VACCINE INJ,95090670,CDM,636,RC,90674,HCPCS,Outpatient,,,474,474,,,,,,Other,Not Separately Reimbursable,391.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,391.05,82.5,,312.84,percent of total billed charges,Pays at 82.5% of total Billed charges,346.02,73,,276.816,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,331.8,70,,265.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.96,19.19,,72.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,237,50,,189.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.96,391.05,
FLU VACCINE PFS: 0.5ML FLUCELVAX,95090674,CDM,636,RC,90686,HCPCS,Outpatient,,,235,235,,,,,,Other,Not Separately Reimbursable,193.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,193.88,82.5,,155.104,percent of total billed charges,Pays at 82.5% of total Billed charges,171.55,73,,137.24,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,164.5,70,,131.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.1,19.19,,36.08,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,117.5,50,,94,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,45.1,193.88,
Flu shot-high dose for 2019-2020 flu season given by injection for people >65,95090686,CDM,636,RC,90715,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,24.75,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,24.75,82.5,,19.8,percent of total billed charges,Pays at 82.5% of total Billed charges,21.9,73,,17.52,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21,70,,16.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,19.19,,4.608,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15,50,,12,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.76,24.75,
"Diphtheria, tetanus acellular, and pertussis vaccine for adults",95090715,CDM,636,RC,90732,HCPCS,Outpatient,,,102,102,,,,,,Other,Not Separately Reimbursable,84.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,84.15,82.5,,67.32,percent of total billed charges,Pays at 82.5% of total Billed charges,74.46,73,,59.568,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,71.4,70,,57.12,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,19.19,,15.656,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51,50,,40.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.57,84.15,
pneumococcal Pneumococcal vaccine,95090732,CDM,636,RC,93005,HCPCS,Outpatient,,,474,474,,,,,,Other,Not Separately Reimbursable,391.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,391.05,82.5,,312.84,percent of total billed charges,Pays at 82.5% of total Billed charges,346.02,73,,276.816,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,331.8,70,,265.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.96,19.19,,72.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,237,50,,189.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,90.96,391.05,
ELECTROCARDIOGRAM,95093005,CDM,730,RC,95115,HCPCS,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,113.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,113.84,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,13.87,73,,11.096,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13.3,70,,10.64,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,19.19,,2.92,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,9.5,50,,7.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,3.65,113.84,
Allergy shot-1 shot,95095115,CDM,510,RC,95117,HCPCS,Outpatient,,,26,26,,,,,,Other,Not Separately Reimbursable,21.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,21.45,82.5,,17.16,percent of total billed charges,Pays at 82.5% of total Billed charges,18.98,73,,15.184,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.2,70,,14.56,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,19.19,,3.992,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,13,50,,10.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,4.99,21.45,
Multiple allergy shots,95095117,CDM,510,RC,96372,HCPCS,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,25.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,25.58,82.5,,20.464,percent of total billed charges,Pays at 82.5% of total Billed charges,22.63,73,,18.104,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.7,70,,17.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,19.19,,4.76,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.5,50,,12.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.95,25.58,
INJECTION ADMINISTRATION,95096372,CDM,510,RC,99201,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,37.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,37.13,82.5,,29.704,percent of total billed charges,Pays at 82.5% of total Billed charges,32.85,73,,26.28,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,31.5,70,,25.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,19.19,,6.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,22.5,50,,18,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,8.64,37.13,
OFFICE VISIT 10 MIN NEW,95099201,CDM,510,RC,99202,HCPCS,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,23.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.93,82.5,,19.144,percent of total billed charges,Pays at 82.5% of total Billed charges,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,23.93,
"New patient office or other outpatient visit, typically 10 minutes",95099202,CDM,510,RC,99203,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
"New patient office or other outpatient visit, typically 30 min",95099203,CDM,510,RC,99204,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,69.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,69.3,82.5,,55.44,percent of total billed charges,Pays at 82.5% of total Billed charges,61.32,73,,49.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.8,70,,47.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,19.19,,12.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,50,,33.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,69.3,
"New patient office of other outpatient visit, typically 45 min",95099204,CDM,510,RC,99205,HCPCS,Outpatient,,,111,111,,,,,,Other,Not Separately Reimbursable,91.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,91.58,82.5,,73.264,percent of total billed charges,Pays at 82.5% of total Billed charges,81.03,73,,64.824,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.7,70,,62.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.3,19.19,,17.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.5,50,,44.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.3,91.58,
"New patient office of other outpatient visit, typically 60 min",95099205,CDM,510,RC,99211,HCPCS,Outpatient,,,184,184,,,,,,Other,Not Separately Reimbursable,151.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,151.8,82.5,,121.44,percent of total billed charges,Pays at 82.5% of total Billed charges,134.32,73,,107.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.8,70,,103.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,19.19,,28.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92,50,,73.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,151.8,
Outpatient visit of established patient not requiring a physician,95099211,CDM,510,RC,99212,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
Outpatient visit of established patient requiring a physician,95099212,CDM,510,RC,99213,HCPCS,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,23.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.1,82.5,,18.48,percent of total billed charges,Pays at 82.5% of total Billed charges,20.44,73,,16.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.6,70,,15.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,19.19,,4.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,50,,11.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,23.1,
"Established patient office or other outpatient visit, typically 15 minutes",95099213,CDM,510,RC,99214,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
"Established patient office or other outpatient visit, typically 25 minutes",95099214,CDM,510,RC,99215,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
"Established patient office or other outpatient, visit typically 40 minutes",95099215,CDM,510,RC,99490,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
"CHRONIC CARE MGMT SVC, 20 MIN",95099490,CDM,510,RC,99495,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,28.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,28.88,82.5,,23.104,percent of total billed charges,Pays at 82.5% of total Billed charges,25.55,73,,20.44,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,24.5,70,,19.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,19.19,,5.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,17.5,50,,14,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,6.72,28.88,
TRANS CARE MGMT 14 DAY DISCH,95099495,CDM,510,RC,99496,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
TRANS CARE MGMT 7 DAY DISCH,95099496,CDM,510,RC,99497,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately Reimbursable,143.55,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,143.55,82.5,,114.84,percent of total billed charges,Pays at 82.5% of total Billed charges,127.02,73,,101.616,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,121.8,70,,97.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.39,19.19,,26.712,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87,50,,69.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,33.39,143.55,
"ADVANCED CARE PLANNING, 30 MIN",95099497,CDM,510,RC,99498,HCPCS,Outpatient,,,86,86,,,,,,Other,Not Separately Reimbursable,70.95,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.95,82.5,,56.76,percent of total billed charges,Pays at 82.5% of total Billed charges,62.78,73,,50.224,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60.2,70,,48.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,19.19,,13.2,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43,50,,34.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.5,70.95,
"ADVANCED CARE PLANNING, EA ADDL 30 MIN",95099498,CDM,510,RC,99201,HCPCS,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,66,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,66,82.5,,52.8,percent of total billed charges,Pays at 82.5% of total Billed charges,58.4,73,,46.72,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,70,,44.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,19.19,,12.28,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40,50,,32,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,15.35,66,
OFFICE VISIT 10 MIN NEW,95199201,CDM,510,RC,99202,HCPCS,Outpatient,,,29,29,,,,,,Other,Not Separately Reimbursable,23.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.93,82.5,,19.144,percent of total billed charges,Pays at 82.5% of total Billed charges,21.17,73,,16.936,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.3,70,,16.24,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,19.19,,4.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.5,50,,11.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.57,23.93,
OFFICE VISIT 20 MIN NEW,95199202,CDM,510,RC,99203,HCPCS,Outpatient,,,55,55,,,,,,Other,Not Separately Reimbursable,45.38,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,45.38,82.5,,36.304,percent of total billed charges,Pays at 82.5% of total Billed charges,40.15,73,,32.12,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,38.5,70,,30.8,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,19.19,,8.44,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,27.5,50,,22,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.55,45.38,
OFFICE VISIT 30 MIN NEW,95199203,CDM,510,RC,99204,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,69.3,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,69.3,82.5,,55.44,percent of total billed charges,Pays at 82.5% of total Billed charges,61.32,73,,49.056,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.8,70,,47.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,19.19,,12.896,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42,50,,33.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.12,69.3,
OFFICE VISIT 45 MIN NEW,95199204,CDM,510,RC,99205,HCPCS,Outpatient,,,111,111,,,,,,Other,Not Separately Reimbursable,91.58,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,91.58,82.5,,73.264,percent of total billed charges,Pays at 82.5% of total Billed charges,81.03,73,,64.824,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,77.7,70,,62.16,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.3,19.19,,17.04,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,55.5,50,,44.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.3,91.58,
OFFICE VISIT 60 MIN NEW,95199205,CDM,510,RC,99211,HCPCS,Outpatient,,,184,184,,,,,,Other,Not Separately Reimbursable,151.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,151.8,82.5,,121.44,percent of total billed charges,Pays at 82.5% of total Billed charges,134.32,73,,107.456,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,128.8,70,,103.04,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,19.19,,28.248,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,92,50,,73.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,35.31,151.8,
OFFICE VISIT 5 MIN EST,95199211,CDM,510,RC,99212,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,8.25,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,8.25,82.5,,6.6,percent of total billed charges,Pays at 82.5% of total Billed charges,7.3,73,,5.84,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,7,70,,5.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,19.19,,1.536,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5,50,,4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,1.92,8.25,
OFFICE VISIT 10 MIN EST,95199212,CDM,510,RC,99213,HCPCS,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,23.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,23.1,82.5,,18.48,percent of total billed charges,Pays at 82.5% of total Billed charges,20.44,73,,16.352,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,19.6,70,,15.68,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,19.19,,4.296,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14,50,,11.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,5.37,23.1,
OFFICE VISIT 15 MIN EST,95199213,CDM,510,RC,99214,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,46.2,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,46.2,82.5,,36.96,percent of total billed charges,Pays at 82.5% of total Billed charges,40.88,73,,32.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.2,70,,31.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,19.19,,8.6,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28,50,,22.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.75,46.2,
OFFICE VISIT 25 MIN EST,95199214,CDM,510,RC,99215,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,70.13,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,70.13,82.5,,56.104,percent of total billed charges,Pays at 82.5% of total Billed charges,62.05,73,,49.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.5,70,,47.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,19.19,,13.048,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,42.5,50,,34,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,16.31,70.13,
OFFICE VISIT 40 MIN EST,95199215,CDM,510,RC,G0237,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,99,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,99,82.5,,79.2,percent of total billed charges,Pays at 82.5% of total Billed charges,87.6,73,,70.08,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,84,70,,67.2,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,19.19,,18.424,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,60,50,,48,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,23.03,99,
CR PULM REHAB NON COPD 1ST 15 MIN,97000237,CDM,943,RC,G0238,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
CR PULM REHAB NON COPD EACH ADD'L,97000238,CDM,943,RC,G0424,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,52.8,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,52.8,82.5,,42.24,percent of total billed charges,Pays at 82.5% of total Billed charges,46.72,73,,37.376,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.8,70,,35.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,19.19,,9.824,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,32,50,,25.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,12.28,52.8,
CR PULM REHAB COPD,97000424,CDM,943,RC,92953,HCPCS,Outpatient,,,112,112,,,,,,Other,Not Separately Reimbursable,92.4,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,92.4,82.5,,73.92,percent of total billed charges,Pays at 82.5% of total Billed charges,81.76,73,,65.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.4,70,,62.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,19.19,,17.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,50,,44.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,92.4,
CR EXTERNAL PACING,97092953,CDM,943,RC,92960,HCPCS,Outpatient,,,1025,1025,,,,,,Other,Not Separately Reimbursable,845.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,845.63,82.5,,676.504,percent of total billed charges,Pays at 82.5% of total Billed charges,748.25,73,,598.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,717.5,70,,574,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,196.7,19.19,,157.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,512.5,50,,410,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,196.7,845.63,
CR CARDIOVERSION,97092960,CDM,943,RC,93017,HCPCS,Outpatient,,,1025,1025,,,,,,Other,Not Separately Reimbursable,845.63,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,845.63,82.5,,676.504,percent of total billed charges,Pays at 82.5% of total Billed charges,748.25,73,,598.6,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,717.5,70,,574,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,196.7,19.19,,157.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,512.5,50,,410,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,196.7,845.63,
CR PHARMOCOL STRESS,97093017,CDM,943,RC,93041,HCPCS,Outpatient,,,498,498,,,,,,Other,Not Separately Reimbursable,426.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,426.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,363.54,73,,290.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,348.6,70,,278.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.57,19.19,,76.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,249,50,,199.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.57,426.6,
CR RHYTHM STRIP EKG,97093041,CDM,730,RC,93270,HCPCS,Outpatient,,,112,112,,,,,,Other,Not Separately Reimbursable,37.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,37.14,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,81.76,73,,65.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.4,70,,62.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,19.19,,17.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,50,,44.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,81.76,
CR EVENT MONITOR PLACE,97093270,CDM,943,RC,93312,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,61.88,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.88,82.5,,49.504,percent of total billed charges,Pays at 82.5% of total Billed charges,54.75,73,,43.8,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.5,70,,42,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,19.19,,11.512,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37.5,50,,30,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.39,61.88,
CR TRANSESOPHAGEAL ECHO,97093312,CDM,943,RC,93350,HCPCS,Outpatient,,,973,973,,,,,,Other,Not Separately Reimbursable,412.18,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,412.18,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,710.29,73,,568.232,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,681.1,70,,544.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.72,19.19,,149.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,486.5,50,,389.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.72,710.29,
Stress test with echocardiogram,97093350,CDM,943,RC,93352,HCPCS,Outpatient,,,973,973,,,,,,Other,Not Separately Reimbursable,190.23,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,190.23,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,710.29,73,,568.232,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,681.1,70,,544.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.72,19.19,,149.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,486.5,50,,389.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.72,710.29,
CR US ADMIN STRESS ECHO CONTRAST,97093352,CDM,943,RC,93660,HCPCS,Outpatient,,,306,306,,,,,,Other,Not Separately Reimbursable,252.45,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,252.45,82.5,,201.96,percent of total billed charges,Pays at 82.5% of total Billed charges,223.38,73,,178.704,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,214.2,70,,171.36,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,19.19,,46.976,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,153,50,,122.4,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,58.72,252.45,
CR TILT TABLE,97093660,CDM,943,RC,93797,HCPCS,Outpatient,,,889,889,,,,,,Other,Not Separately Reimbursable,733.43,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,733.43,82.5,,586.744,percent of total billed charges,Pays at 82.5% of total Billed charges,648.97,73,,519.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,622.3,70,,497.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.6,19.19,,136.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,444.5,50,,355.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.6,733.43,
CR W/O ECG MONITORING,97093797,CDM,943,RC,93798,HCPCS,Outpatient,,,233,233,,,,,,Other,Not Separately Reimbursable,192.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,192.23,82.5,,153.784,percent of total billed charges,Pays at 82.5% of total Billed charges,170.09,73,,136.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.1,70,,130.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.71,19.19,,35.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.5,50,,93.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.71,192.23,
Use of EKG to monitor cardiac rehabilitation,97093798,CDM,943,RC,93799,HCPCS,Outpatient,,,233,233,,,,,,Other,Not Separately Reimbursable,192.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,192.23,82.5,,153.784,percent of total billed charges,Pays at 82.5% of total Billed charges,170.09,73,,136.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.1,70,,130.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.71,19.19,,35.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.5,50,,93.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.71,192.23,
CR CARDIO-ABORTED PROC,97093799,CDM,943,RC,94618,HCPCS,Outpatient,,,273,273,,,,,,Other,Not Separately Reimbursable,225.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,225.23,82.5,,180.184,percent of total billed charges,Pays at 82.5% of total Billed charges,199.29,73,,159.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191.1,70,,152.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.39,19.19,,41.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,136.5,50,,109.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.39,225.23,
CR PULM STRESS TEST 6 MIN,97094618,CDM,943,RC,95860,HCPCS,Outpatient,,,210,210,,,,,,Other,Not Separately Reimbursable,150.98,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,150.98,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,153.3,73,,122.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,70,,117.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,19.19,,32.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,50,,84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,153.3,
Test to measure electrical activity of muscles or nerves in 1 limb,97095860,CDM,943,RC,95885,HCPCS,Outpatient,,,210,210,,,,,,Other,Not Separately Reimbursable,40.76,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,40.76,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,153.3,73,,122.64,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147,70,,117.6,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,19.19,,32.24,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,105,50,,84,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,40.3,153.3,
CR EMG W/NCS LIMITED,97095885,CDM,943,RC,95886,HCPCS,Outpatient,,,108,108,,,,,,Other,Not Separately Reimbursable,89.1,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,89.1,82.5,,71.28,percent of total billed charges,Pays at 82.5% of total Billed charges,78.84,73,,63.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,75.6,70,,60.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.73,19.19,,16.584,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,54,50,,43.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,20.73,89.1,
Test to assess for nerve damage,97095886,CDM,943,RC,95907,HCPCS,Outpatient,,,149,149,,,,,,Other,Not Separately Reimbursable,122.93,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,122.93,82.5,,98.344,percent of total billed charges,Pays at 82.5% of total Billed charges,108.77,73,,87.016,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,104.3,70,,83.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,19.19,,22.872,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,74.5,50,,59.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.59,122.93,
CR EMG NCS 1-2,97095907,CDM,943,RC,95908,HCPCS,Outpatient,,,273,273,,,,,,Other,Not Separately Reimbursable,51.85,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,51.85,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,199.29,73,,159.432,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191.1,70,,152.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,52.39,19.19,,41.912,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,136.5,50,,109.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.85,199.29,
CR EMG NCS 3-4,97095908,CDM,943,RC,95909,HCPCS,Outpatient,,,498,498,,,,,,Other,Not Separately Reimbursable,103.7,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,103.7,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,363.54,73,,290.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,348.6,70,,278.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.57,19.19,,76.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,249,50,,199.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.57,363.54,
CR EMG NCS 5-6,97095909,CDM,943,RC,95910,HCPCS,Outpatient,,,498,498,,,,,,Other,Not Separately Reimbursable,155.55,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,155.55,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,363.54,73,,290.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,348.6,70,,278.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.57,19.19,,76.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,249,50,,199.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.57,363.54,
CR EMG NCS 7-8,97095910,CDM,943,RC,95911,HCPCS,Outpatient,,,498,498,,,,,,Other,Not Separately Reimbursable,207.4,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,207.4,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,363.54,73,,290.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,348.6,70,,278.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.57,19.19,,76.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,249,50,,199.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.57,363.54,
CR EMG NCS 9-10,97095911,CDM,943,RC,95912,HCPCS,Outpatient,,,889,889,,,,,,Other,Not Separately Reimbursable,259.25,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,259.25,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,648.97,73,,519.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,622.3,70,,497.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.6,19.19,,136.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,444.5,50,,355.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.6,648.97,
CR EMG NCS 11-12,97095912,CDM,943,RC,95913,HCPCS,Outpatient,,,889,889,,,,,,Other,Not Separately Reimbursable,311.09,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,311.09,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,648.97,73,,519.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,622.3,70,,497.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.6,19.19,,136.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,444.5,50,,355.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.6,648.97,
CR EMG NCS 13 OR MORE,97095913,CDM,943,RC,95933,HCPCS,Outpatient,,,889,889,,,,,,Other,Not Separately Reimbursable,337.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,337.02,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,648.97,73,,519.176,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,622.3,70,,497.84,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.6,19.19,,136.48,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,444.5,50,,355.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,170.6,648.97,
CR BLINK,97095933,CDM,943,RC,96365,HCPCS,Outpatient,,,112,112,,,,,,Other,Not Separately Reimbursable,84.55,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,84.55,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,81.76,73,,65.408,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,78.4,70,,62.72,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,19.19,,17.192,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,56,50,,44.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,21.49,84.55,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",97096365,CDM,943,RC,96379,HCPCS,Outpatient,,,382,382,,,,,,Other,Not Separately Reimbursable,315.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,315.15,82.5,,252.12,percent of total billed charges,Pays at 82.5% of total Billed charges,278.86,73,,223.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,267.4,70,,213.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.31,19.19,,58.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191,50,,152.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.31,315.15,
CR SUP IV START,97096379,CDM,943,RC,93017,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,61.05,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,61.05,82.5,,48.84,percent of total billed charges,Pays at 82.5% of total Billed charges,54.02,73,,43.216,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,51.8,70,,41.44,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,19.19,,11.36,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,37,50,,29.6,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.2,61.05,
CR STRESS TEST,97193017,CDM,943,RC,93312,HCPCS,Outpatient,,,498,498,,,,,,Other,Not Separately Reimbursable,426.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,426.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,363.54,73,,290.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,348.6,70,,278.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.57,19.19,,76.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,249,50,,199.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.57,426.6,
CR TRANSESOPHAGEAL ECHO,97193312,CDM,943,RC,93350,HCPCS,Outpatient,,,973,973,,,,,,Other,Not Separately Reimbursable,412.18,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,412.18,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,710.29,73,,568.232,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,681.1,70,,544.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.72,19.19,,149.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,486.5,50,,389.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.72,710.29,
Stress test with echocardiogram,97193350,CDM,943,RC,93798,HCPCS,Outpatient,,,973,973,,,,,,Other,Not Separately Reimbursable,190.23,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,190.23,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,710.29,73,,568.232,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,681.1,70,,544.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.72,19.19,,149.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,486.5,50,,389.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.72,710.29,
Use of EKG to monitor cardiac rehabilitation,97193798,CDM,943,RC,96365,HCPCS,Outpatient,,,233,233,,,,,,Other,Not Separately Reimbursable,192.23,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,192.23,82.5,,153.784,percent of total billed charges,Pays at 82.5% of total Billed charges,170.09,73,,136.072,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,163.1,70,,130.48,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.71,19.19,,35.768,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,116.5,50,,93.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,44.71,192.23,
"Intravenous infusion, for therapy, prophylaxis, or diagnosis-initial infusion",97196365,CDM,943,RC,93017,HCPCS,Outpatient,,,382,382,,,,,,Other,Not Separately Reimbursable,315.15,82.5,,,percent of total billed charges,Pays at 82.5% of total Billed charges,315.15,82.5,,252.12,percent of total billed charges,Pays at 82.5% of total Billed charges,278.86,73,,223.088,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,267.4,70,,213.92,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.31,19.19,,58.648,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,191,50,,152.8,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,73.31,315.15,
CR NUCLEAR STRESS TEST WALKING,97293017,CDM,943,RC,93312,HCPCS,Outpatient,,,498,498,,,,,,Other,Not Separately Reimbursable,426.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,426.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,363.54,73,,290.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,348.6,70,,278.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.57,19.19,,76.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,249,50,,199.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.57,426.6,
CR TEE W/BUBBLE STUDY,97293312,CDM,943,RC,93017,HCPCS,Outpatient,,,973,973,,,,,,Other,Not Separately Reimbursable,412.18,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,412.18,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,710.29,73,,568.232,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,681.1,70,,544.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.72,19.19,,149.376,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,486.5,50,,389.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,186.72,710.29,
CR DOBUTAMINE NUC STRESS TEST,97393017,CDM,943,RC,93017,HCPCS,Outpatient,,,498,498,,,,,,Other,Not Separately Reimbursable,426.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,426.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,363.54,73,,290.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,348.6,70,,278.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.57,19.19,,76.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,249,50,,199.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.57,426.6,
CR LEXISCAN NUC STRESS TEST,97493017,CDM,943,RC,11732,HCPCS,Outpatient,,,498,498,,,,,,Other,Not Separately Reimbursable,426.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,426.6,315,,,fee schedule,Pays at 315% of BCBS fee schedule Outpatient Setting,363.54,73,,290.832,percent of total billed charges,Pays at 73% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,348.6,70,,278.88,percent of total billed charges,Pays at 70% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.57,19.19,,76.456,percent of total billed charges,Pays at 19.19% of Total Billed charges,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,249,50,,199.2,percent of total billed charges,Pays at 50% of total billed charges for outpatient setting,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,95.57,426.6,
"RMV NAIL PLATE, ADD-ON",6711732,CDM,983,RC,12047,HCPCS,Outpatient,,,23,23,,,,,,Other,Not Separately Reimbursable,34.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,34.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,20.37,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,11.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,20.37,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,11.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,11.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,11.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,20.37,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,11.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,11.77,34.25,
INTER REPAIR>30.0CM,6791247,CDM,983,RC,99201,HCPCS,Outpatient,,,427,427,,,,,,Other,Not Separately Reimbursable,395.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,395.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,220.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,422.92,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,220.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,422.92,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,220.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,220.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,220.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,422.92,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,220.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,220.44,422.92,
OFFICE VISIT 10 MIN NEW,6799202,CDM,983,RC,10021,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,34.44,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,34.44,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.44,34.44,
Fine Needle Aspiration Biopsy without imaging,12010021,CDM,981,RC,10061,HCPCS,Outpatient,,,204,204,,,,,,Other,Not Separately Reimbursable,89.29,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,89.29,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.92,89.29,
EDP I&D MULTIPLE ABSCESS COMPLICATED,12010061,CDM,981,RC,10081,HCPCS,Outpatient,,,422,422,,,,,,Other,Not Separately Reimbursable,158.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,158.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.29,212.07,
"EDP I&D OF PILONIDAL CYST, SIMPLE",12010081,CDM,981,RC,10121,HCPCS,Outpatient,,,397,397,,,,,,Other,Not Separately Reimbursable,187.04,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,187.04,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,116.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,201.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,116.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,201.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,116.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,116.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,116.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,201.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,116.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,116.53,201.42,
EDP I&D FB COMPLEX,12010121,CDM,981,RC,10180,HCPCS,Outpatient,,,487,487,,,,,,Other,Not Separately Reimbursable,196.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,196.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,214.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,214.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,214.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.84,214.35,
"EDP ER I&D, COMPLEX,POST-OP WND INFEC",12010180,CDM,981,RC,11042,HCPCS,Outpatient,,,509,509,,,,,,Other,Not Separately Reimbursable,146.32,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,146.32,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,121.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,211.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,121.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,211.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,121.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,121.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,121.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,211.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,121.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,121.38,211.14,
EDP DEBRIDEMENT OF SKIN/SUBCUT TISSUE,12011042,CDM,981,RC,11420,HCPCS,Outpatient,,,69,69,,,,,,Other,Not Separately Reimbursable,78.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,78.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.61,78.03,
EXC-BENIGN SP/NK/H/F/G <0.5 CM,12011420,CDM,981,RC,11422,HCPCS,Outpatient,,,231,231,,,,,,Other,Not Separately Reimbursable,103.65,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,103.65,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.61,103.65,
Under Excision-Benign Lesions Procedures on the Skin 1.1-2 CM,12011422,CDM,981,RC,11760,HCPCS,Outpatient,,,350,350,,,,,,Other,Not Separately Reimbursable,149.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,149.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,91.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,156.66,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,91.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,156.66,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,91.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,91.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,91.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,156.66,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,91.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,91.61,156.66,
EDP REPAIR BED NAIL,12011760,CDM,981,RC,11765,HCPCS,Outpatient,,,345,345,,,,,,Other,Not Separately Reimbursable,122.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,122.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,75.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,128.11,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,75.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,128.11,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,75.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,75.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,75.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,128.11,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,75.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,75.45,128.11,
EDP WEDGE EXCISION OF SKIN / NAIL FOLD,12011765,CDM,981,RC,11770,HCPCS,Outpatient,,,97,97,,,,,,Other,Not Separately Reimbursable,59.01,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,59.01,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,62.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.21,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,62.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.21,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,62.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,62.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.21,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,62.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,59.01,105.21,
EDP EXCIS OF PILONIDAL CYST OR SINUS;SIM,12011770,CDM,981,RC,11771,HCPCS,Outpatient,,,439,439,,,,,,Other,Not Separately Reimbursable,215.77,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,215.77,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,127.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,221.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,221.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,127.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,127.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,221.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,127.61,221.27,
EDP EXCIS OF PILONIDAL CYST OR SINUS;EXT,12011771,CDM,981,RC,11772,HCPCS,Outpatient,,,1042,1042,,,,,,Other,Not Separately Reimbursable,430.28,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,430.28,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,304.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,535.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,304.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,535.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,304.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,304.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,304.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,535.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,304.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,304.95,535.52,
EDP EXCIS OF PILONIDAL CYST OR SINUS;COM,12011772,CDM,981,RC,12015,HCPCS,Outpatient,,,1363,1363,,,,,,Other,Not Separately Reimbursable,506.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,506.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,399.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,685.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,399.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,685.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,399.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,399.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,399.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,685.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,399.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,399.28,685.91,
EDP SURG PROC FEE 7.6CM TO 12.5CM,12012015,CDM,981,RC,12020,HCPCS,Outpatient,,,741,741,,,,,,Other,Not Separately Reimbursable,236.68,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,236.68,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.38,236.68,
EDP TX SUPERFICIAL WOUND DEHISCENCE SIMP,12012020,CDM,981,RC,12021,HCPCS,Outpatient,,,537,537,,,,,,Other,Not Separately Reimbursable,192.6,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,192.6,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,220.67,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,220.67,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,220.67,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,192.6,220.67,
EDP TRMT OF SUPERFICIAL WND W/PACKING,12012021,CDM,981,RC,12035,HCPCS,Outpatient,,,404,404,,,,,,Other,Not Separately Reimbursable,141.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,141.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,164.61,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,164.61,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,164.61,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,141.1,164.61,
EDP INTER WOUNDS STE 12.6 TO 20.0 CM,12012035,CDM,981,RC,99281,HCPCS,Outpatient,,,375,375,,,,,,Other,Not Separately Reimbursable,244.63,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,244.63,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,163.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,283.95,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,163.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,283.95,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,163.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,163.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,163.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,283.95,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,163.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,163.6,283.95,
EDP ER VISIT MINOR PF,12012500,CDM,981,RC,99282,HCPCS,Outpatient,,,165,165,,,,,,Other,Not Separately Reimbursable,18.37,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,18.37,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,15.36,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,14.19,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,15.36,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,14.19,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,15.36,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,15.36,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,15.36,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,14.19,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,15.36,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,14.19,18.37,
EDP ER VISIT LOW,12012505,CDM,981,RC,99283,HCPCS,Outpatient,,,204,204,,,,,,Other,Not Separately Reimbursable,29.97,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,29.97,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,29.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.76,49.59,
"Emergency department visit, moderately severe problem",12012515,CDM,981,RC,99284,HCPCS,Outpatient,,,308,308,,,,,,Other,Not Separately Reimbursable,63.63,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,63.63,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,45.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,85.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,85.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,45.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,45.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,85.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,45.8,85.34,
"Emergency department visit, problem of high severity",12012517,CDM,981,RC,99291,HCPCS,Outpatient,,,586,586,,,,,,Other,Not Separately Reimbursable,98.98,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,98.98,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,84.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,142.92,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,84.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,142.92,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,84.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,84.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,84.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,142.92,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,84.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,84.15,142.92,
EDP CRITICAL CARE FIRST HOUR,12012518,CDM,981,RC,99285,HCPCS,Outpatient,,,1092,1092,,,,,,Other,Not Separately Reimbursable,213.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,213.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,146.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,250.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,146.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,250.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,146.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,146.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,146.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,250.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,146.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,146.07,250.03,
"Emergency department visit, problem with significant threat to life or function",12012519,CDM,981,RC,99281,HCPCS,Outpatient,,,856,856,,,,,,Other,Not Separately Reimbursable,154.72,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,154.72,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,122.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,208.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,122.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,208.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,122.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,122.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,208.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,122.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.23,208.56,
EDP ER VISIT MINOR W/PROCEDURE PF,12012601,CDM,981,RC,99282,HCPCS,Outpatient,,,165,165,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
EDP ER VISIT LOW W/PROCEDURE,12012602,CDM,981,RC,99283,HCPCS,Outpatient,,,204,204,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
EDP ER VISIT MODERATE W/PROCEDURE,12012603,CDM,981,RC,99284,HCPCS,Outpatient,,,308,308,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
EDP ER VISIT HIGH W/PROCEDURE,12012604,CDM,981,RC,99285,HCPCS,Outpatient,,,586,586,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
EDP ER VISIT LIFE THREATENING W/PROC,12012605,CDM,981,RC,99291,HCPCS,Outpatient,,,856,856,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
EDP CRITICAL CARE FIRST HOUR W/PROC,12012607,CDM,981,RC,99292,HCPCS,Outpatient,,,1092,1092,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
EDP CRITICAL CARE ADD'L 30 MIN,12012608,CDM,981,RC,92960,HCPCS,Outpatient,,,549,549,,,,,,Other,Not Separately Reimbursable,107.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,107.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,73.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,125.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,73.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,125.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,73.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,73.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,73.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,125.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,73.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,73.38,125.76,
EDP CARDIOVERSION,12012610,CDM,981,RC,92950,HCPCS,Outpatient,,,306,306,,,,,,Other,Not Separately Reimbursable,165.79,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,165.79,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,72.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,72.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,72.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,72.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,72.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,72.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,72.92,165.79,
EDP CPR,12012613,CDM,981,RC,62270,HCPCS,Outpatient,,,295,295,,,,,,Other,Not Separately Reimbursable,211.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,211.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,124.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,213.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,213.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,124.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,213.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.38,213.99,
EDP DIAG SPINAL LUMBAR PUNCT,12012614,CDM,981,RC,12001,HCPCS,Outpatient,,,514,514,,,,,,Other,Not Separately Reimbursable,146.93,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,146.93,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,75.57,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,75.57,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,75.57,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,42,146.93,
"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",12012621,CDM,981,RC,12002,HCPCS,Outpatient,,,355,355,,,,,,Other,Not Separately Reimbursable,138.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,138.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.32,138.33,
EDP SURG PROC SNT 2.6 TO 7.5 CM,12012622,CDM,981,RC,12004,HCPCS,Outpatient,,,458,458,,,,,,Other,Not Separately Reimbursable,150,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,150,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.15,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.15,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.15,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.11,150,
EDP SURG PROC SNT 7.6 TO 12.5CM,12012623,CDM,981,RC,12005,HCPCS,Outpatient,,,559,559,,,,,,Other,Not Separately Reimbursable,173.87,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,173.87,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.61,173.87,
EDP SURG PROC SNT 12.6 T0 20 CM,12012624,CDM,981,RC,12011,HCPCS,Outpatient,,,739,739,,,,,,Other,Not Separately Reimbursable,215.91,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,215.91,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.84,215.91,
"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes",12012625,CDM,981,RC,12013,HCPCS,Outpatient,,,430,430,,,,,,Other,Not Separately Reimbursable,144.69,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,144.69,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,66.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,66.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,66.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,37.61,144.69,
EDP SURG PROC FEE 2.6 TO 5.0 CM,12012626,CDM,981,RC,12014,HCPCS,Outpatient,,,483,483,,,,,,Other,Not Separately Reimbursable,161.51,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,161.51,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,39.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,39.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,39.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,39.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,39.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,39.69,161.51,
EDP SURG PROC FEE 5.1 TO 7.5 CM,12012627,CDM,981,RC,12031,HCPCS,Outpatient,,,602,602,,,,,,Other,Not Separately Reimbursable,190.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,190.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,90.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,90.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,90.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51,190.18,
EDP INTER WOUNDS STE UP TO 2.5 CM,12012628,CDM,981,RC,12032,HCPCS,Outpatient,,,430,430,,,,,,Other,Not Separately Reimbursable,169.88,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,169.88,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,101.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,174.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,101.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,174.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,101.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,101.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,101.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,174.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,101.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,101.99,174.86,
EDP INTER WOUNDS STE 2.6 TO 7.5 CM,12012629,CDM,981,RC,12034,HCPCS,Outpatient,,,516,516,,,,,,Other,Not Separately Reimbursable,187.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,187.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,127.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,218.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,218.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,127.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,127.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,218.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,127.38,218.27,
EDP INTER WOUNDS STE 7.6 TO 12.5 CM,12012630,CDM,981,RC,12041,HCPCS,Outpatient,,,546,546,,,,,,Other,Not Separately Reimbursable,218.6,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,218.6,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,238.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,238.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,238.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,138.44,238.36,
EDP INTER WOUNDS NHF UP TO 2.5 CM,12012631,CDM,981,RC,12042,HCPCS,Outpatient,,,456,456,,,,,,Other,Not Separately Reimbursable,188.13,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,188.13,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,97.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,167.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,97.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,167.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,97.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,97.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,97.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,167.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,97.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,97.15,188.13,
EDP INTER WOUNDS NHF 2.6 TO 7.5 CM,12012632,CDM,981,RC,12044,HCPCS,Outpatient,,,529,529,,,,,,Other,Not Separately Reimbursable,205.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,205.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,131.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,225.16,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,131.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,225.16,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,131.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,131.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,131.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,225.16,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,131.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,131.76,225.16,
EDP INTER WOUNDS NHF 7.6 TO 12.5 CM,12012633,CDM,981,RC,12051,HCPCS,Outpatient,,,852,852,,,,,,Other,Not Separately Reimbursable,231.92,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,231.92,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,143.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,248.83,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,143.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,248.83,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,143.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,143.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,143.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,248.83,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,143.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,143.99,248.83,
EDP INTER WOUNDS FEEN UP TO 2.5 CM,12012634,CDM,981,RC,12052,HCPCS,Outpatient,,,727,727,,,,,,Other,Not Separately Reimbursable,192.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,192.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,113.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,196.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,113.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,196.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,113.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,113.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,113.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,196.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,113.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,113.99,196.04,
EDP INTER WOUNDS FEEN 2.6 TO 5.0 CM,12012635,CDM,981,RC,12053,HCPCS,Outpatient,,,864,864,,,,,,Other,Not Separately Reimbursable,208.13,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,208.13,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,134.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,230.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,230.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,134.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,230.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.07,230.91,
EDP INTER WOUNDS FEEN 5.1 TO 7.5 CM,12012636,CDM,981,RC,13100,HCPCS,Outpatient,,,866,866,,,,,,Other,Not Separately Reimbursable,229.55,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,229.55,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,250.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,250.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,250.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,144.44,250.02,
EDP COMPLEX WOUND REPAIR 1.1 TO 2.5 CM,12012637,CDM,981,RC,13131,HCPCS,Outpatient,,,624,624,,,,,,Other,Not Separately Reimbursable,230.77,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,230.77,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.99,232.33,
EDP COMP WOUND REP FHF 1.1 TO 2.5 CM,12012639,CDM,981,RC,16020,HCPCS,Outpatient,,,737,737,,,,,,Other,Not Separately Reimbursable,275.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,275.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,162.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,279.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,162.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,279.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,162.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,162.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,162.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,279.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,162.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,162.91,279.76,
EDP DRESS/DEBRIDE-SMALL-W/O,12012642,CDM,981,RC,11730,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,65.79,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,65.79,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.49,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.49,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.49,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.92,65.79,
Separation and removal of the entire nail plate or a portion of nail plate,12012645,CDM,981,RC,11740,HCPCS,Outpatient,,,208,208,,,,,,Other,Not Separately Reimbursable,71.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,71.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.22,71.25,
EDP DRAIN SUBUNGAL HEMATO,12012646,CDM,981,RC,11750,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,36.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,36.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,21.22,36.67,
EDP EXCISION-INGROWN NAIL(S),12012647,CDM,981,RC,10060,HCPCS,Outpatient,,,250,250,,,,,,Other,Not Separately Reimbursable,139.63,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,139.63,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,68.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,115.61,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,115.61,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,68.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,115.61,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.53,139.63,
Incision and drainage of abscess; simple or single and complex or multiple,12012648,CDM,981,RC,10080,HCPCS,Outpatient,,,241,241,,,,,,Other,Not Separately Reimbursable,87.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,87.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.7,120.26,
EDP I&D PILONIDAL CYST SIMPLE,12012649,CDM,981,RC,10120,HCPCS,Outpatient,,,144,144,,,,,,Other,Not Separately Reimbursable,107.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,107.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,70.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.92,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.92,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,70.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.92,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.62,120.92,
EDP I&D REMOVAL FB SIMPLE,12012650,CDM,981,RC,10140,HCPCS,Outpatient,,,239,239,,,,,,Other,Not Separately Reimbursable,102.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,102.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,121.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,121.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,121.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.15,121.26,
"Incision and drainage of hematoma, seroma or fluid collection",12012651,CDM,981,RC,11042,HCPCS,Outpatient,,,306,306,,,,,,Other,Not Separately Reimbursable,106.54,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,106.54,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,80.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,136.25,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,136.25,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,80.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,136.25,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.06,136.25,
EDP DEBRIDE SKIN PARTIAL THICK,12012652,CDM,981,RC,10160,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,78.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,78.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,59.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,59.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,59.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.61,78.03,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",12012653,CDM,981,RC,69200,HCPCS,Outpatient,,,248,248,,,,,,Other,Not Separately Reimbursable,94.05,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,94.05,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.38,111.8,
EDP REMOVAL FB EAR W/O ANES,12012654,CDM,981,RC,69210,HCPCS,Outpatient,,,227,227,,,,,,Other,Not Separately Reimbursable,73.23,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,73.23,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,31.94,73.23,
Removal of ear wax from one or both ears,12012655,CDM,981,RC,30300,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,61.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,61.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,22.38,61.33,
EDP REMOVAL FB INTRA-NASAL,12012656,CDM,981,RC,30901,HCPCS,Outpatient,,,180,180,,,,,,Other,Not Separately Reimbursable,115.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,115.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,77.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,143.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,143.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,77.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,77.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,143.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,77.31,143.3,
EDP EPISTAX ANT UNI/BIL SIMPLE,12012657,CDM,981,RC,30903,HCPCS,Outpatient,,,234,234,,,,,,Other,Not Separately Reimbursable,110.83,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,110.83,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.25,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,38.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.25,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,38.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,38.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.25,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,38.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.25,110.83,
EDP EPISTAX ANT UNI/BL COMPLEX,12012658,CDM,981,RC,30905,HCPCS,Outpatient,,,332,332,,,,,,Other,Not Separately Reimbursable,138.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,138.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,52.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,93.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,52.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,93.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,52.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,52.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,52.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,93.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,52.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,52.38,138.75,
EDP EPISTAXIS WITH POST PACK,12012659,CDM,981,RC,31500,HCPCS,Outpatient,,,677,677,,,,,,Other,Not Separately Reimbursable,214.97,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,214.97,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,71.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,127.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,127.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,71.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,127.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.76,214.97,
EDP ENDOTRACHEAL INTUBATION,12012660,CDM,981,RC,31511,HCPCS,Outpatient,,,449,449,,,,,,Other,Not Separately Reimbursable,123.7,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,123.7,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,98.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,168.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,98.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,168.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,98.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,98.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,98.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,168.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,98.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,98.71,168.33,
EDP REMOV FB LARYNGOSCOPY,12012661,CDM,981,RC,G0168,HCPCS,Outpatient,,,221,221,,,,,,Other,Not Separately Reimbursable,177.63,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,177.63,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,89.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,157.18,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,89.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,157.18,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,89.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,89.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,89.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,157.18,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,89.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,89.53,177.63,
EDP DERMABOND WND CLOSURE,12012663,CDM,981,RC,32551,HCPCS,Outpatient,,,129,129,,,,,,Other,Not Separately Reimbursable,82.13,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,82.13,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,18.03,82.13,
EDP CHEST TUBE INSERTION,12012664,CDM,981,RC,64450,HCPCS,Outpatient,,,715,715,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,110.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,185.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,110.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,185.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,110.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,110.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,110.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,185.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,110.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,110.63,185.43,
EDP NERVE BLOCK PERIPHERAL,12012665,CDM,981,RC,65205,HCPCS,Outpatient,,,436,436,,,,,,Other,Not Separately Reimbursable,102.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,102.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,28.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,28.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,28.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,28.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,28.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,28.61,102.42,
EDP REMOVE FB CONJUNCTIVA,12012672,CDM,981,RC,65220,HCPCS,Outpatient,,,172,172,,,,,,Other,Not Separately Reimbursable,169.27,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,169.27,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,23.4,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,23.4,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,23.4,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,23.4,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,23.4,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,23.4,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,23.4,169.27,
EDP FB CORNEA W/O SLITLAMP,12012673,CDM,981,RC,23650,HCPCS,Outpatient,,,269,269,,,,,,Other,Not Separately Reimbursable,211.93,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,211.93,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.7,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.7,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,27.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,27.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.7,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,27.69,211.93,
EDP SHOULDER REDUCE W/O ANES,12012674,CDM,981,RC,24600,HCPCS,Outpatient,,,708,708,,,,,,Other,Not Separately Reimbursable,303.05,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,303.05,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,200.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,359.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,200.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,359.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,200.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,200.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,200.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,359.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,200.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,200.11,359.97,
EDP ELBOW DISLOCAT W/O ANES,12012676,CDM,981,RC,24640,HCPCS,Outpatient,,,852,852,,,,,,Other,Not Separately Reimbursable,385.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,385.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,232.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,412.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,232.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,412.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,232.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,232.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,412.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,232.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.43,412.94,
EDP REDUCE RAD HEAD SUBLUX,12012677,CDM,981,RC,27560,HCPCS,Outpatient,,,350,350,,,,,,Other,Not Separately Reimbursable,154.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,154.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,54.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,92.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,54.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,92.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,54.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,54.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,92.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,54.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.1,154.2,
EDP KNEE DISLOCATION-W/O ANES,12012678,CDM,981,RC,26775,HCPCS,Outpatient,,,893,893,,,,,,Other,Not Separately Reimbursable,335.51,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,335.51,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,233.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,410.06,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,233.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,410.06,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,233.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,233.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,233.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,410.06,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,233.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,233.52,410.06,
EDP REDUCE IP JOINT W/ANES,12012680,CDM,981,RC,26770,HCPCS,Outpatient,,,380,380,,,,,,Other,Not Separately Reimbursable,327.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,327.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,238.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,423.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,238.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,423.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,238.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,238.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,238.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,423.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,238.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,238.41,423.3,
EDP REDUCE IP JOINT W/O ANES,12012681,CDM,981,RC,26755,HCPCS,Outpatient,,,636,636,,,,,,Other,Not Separately Reimbursable,255.02,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,255.02,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,177.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,314.93,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,177.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,314.93,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,177.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,177.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,177.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,314.93,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,177.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,177.38,314.93,
EDP CLOSED FINGER W/ MANIPU,12012682,CDM,981,RC,26700,HCPCS,Outpatient,,,698,698,,,,,,Other,Not Separately Reimbursable,272.02,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,272.02,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,188.39,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,330.57,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,188.39,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,330.57,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,188.39,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,188.39,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,188.39,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,330.57,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,188.39,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,188.39,330.57,
EDP REDUCE PHALANX W/O ANES,12012684,CDM,981,RC,20605,HCPCS,Outpatient,,,356,356,,,,,,Other,Not Separately Reimbursable,292.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,292.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,212.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,377.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,212.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,377.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,212.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,212.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,377.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,212.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.09,377.02,
Draining or injecting medication into a large joint/bursa without ultrasound,12012688,CDM,981,RC,20610,HCPCS,Outpatient,,,163,163,,,,,,Other,Not Separately Reimbursable,78.34,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,78.34,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.15,78.34,
Draining or injecting medication into a major joint/bursa without ultrasound,12012689,CDM,981,RC,56420,HCPCS,Outpatient,,,147,147,,,,,,Other,Not Separately Reimbursable,94.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,94.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.69,94.3,
EDP I&D BARTHOLIN ABSCESS,12012691,CDM,981,RC,51701,HCPCS,Outpatient,,,375,375,,,,,,Other,Not Separately Reimbursable,127.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,127.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,71.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,131.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,131.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,71.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,131.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.09,131.05,
EDP BLADDER CATH SIMPLE,12012692,CDM,981,RC,54450,HCPCS,Outpatient,,,179,179,,,,,,Other,Not Separately Reimbursable,58.54,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,58.54,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,17.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,17.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,17.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,17.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,17.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,17.26,58.54,
EDP FORESKIN MANIPULATION,12012693,CDM,981,RC,29075,HCPCS,Outpatient,,,126,126,,,,,,Other,Not Separately Reimbursable,78.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,78.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,66.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,38.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,66.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,38.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,38.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,66.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,38.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.07,78.94,
EDP CASTING OF SHORT ARM,12012700,CDM,981,RC,29105,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,74.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,74.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,74.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,74.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,74.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,41.77,74.05,
EDP APPLICATION OF SPLINT LONG ARM,12012704,CDM,981,RC,29125,HCPCS,Outpatient,,,234,234,,,,,,Other,Not Separately Reimbursable,77.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,77.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.41,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.41,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.41,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,28.71,77.76,
EDP APPLICATION OF SPLINT SHORT ARM,12012705,CDM,981,RC,29130,HCPCS,Outpatient,,,171,171,,,,,,Other,Not Separately Reimbursable,59.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,59.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,47.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,47.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,47.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,27,59.76,
EDP APPLICATION OF SPLINT FINGER,12012706,CDM,981,RC,29505,HCPCS,Outpatient,,,114,114,,,,,,Other,Not Separately Reimbursable,47.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,47.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,19.82,47.58,
EDP APPLICATION OF SPLINT LONG LEG,12012707,CDM,981,RC,29515,HCPCS,Outpatient,,,190,190,,,,,,Other,Not Separately Reimbursable,77.99,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,77.99,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,60.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,60.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,60.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.61,77.99,
EDP APPLICATION OF SPLINT SHORT LEG,12012708,CDM,981,RC,36556,HCPCS,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,66.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,66.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,57.74,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,57.74,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,57.74,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33.22,66.57,
EDP CENTRAL LINE INSERTION ADULT & CHILD,12012715,CDM,981,RC,13121,HCPCS,Outpatient,,,171,171,,,,,,Other,Not Separately Reimbursable,310.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,310.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,99.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,99.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,99.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,57,310.16,
COMP WD SCALP ARMS LEG 2.6-7.5CM,12013121,CDM,981,RC,13122,HCPCS,Outpatient,,,936,936,,,,,,Other,Not Separately Reimbursable,305.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,305.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,297.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,297.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,297.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,173.06,305.43,
"SCALP, ARMS, LEGS; EA ADD'L 5CM OR LESS",12013122,CDM,981,RC,13132,HCPCS,Outpatient,,,246,246,,,,,,Other,Not Separately Reimbursable,91.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,91.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,97.49,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,97.49,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,97.49,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.61,97.49,
"EDP FOREHEAD, HANDS, FEET 2.6-7.5 CM",12013132,CDM,981,RC,13151,HCPCS,Outpatient,,,1258,1258,,,,,,Other,Not Separately Reimbursable,408.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,408.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,203.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,350.72,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,203.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,350.72,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,203.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,203.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,203.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,350.72,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,203.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,203.75,408.09,
"EDP EYELIDS, NOES, EARS, LIPS 1.1-2.5 CM",12013151,CDM,981,RC,13152,HCPCS,Outpatient,,,850,850,,,,,,Other,Not Separately Reimbursable,345.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,345.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,187.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,323.12,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,187.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,323.12,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,187.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,187.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,323.12,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,187.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.6,345.09,
EDP EYELIDS NOSE EARS LIPS 2.6CM-7.5CM,12013152,CDM,981,RC,17250,HCPCS,Outpatient,,,1079,1079,,,,,,Other,Not Separately Reimbursable,466.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,466.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,225.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,389.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,225.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,389.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,225.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,225.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,225.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,389.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,225.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,225.91,466.18,
Chemical destruction of pre-cancerous lesions of the skin,12017250,CDM,981,RC,28660,HCPCS,Outpatient,,,105,105,,,,,,Other,Not Separately Reimbursable,42.01,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,42.01,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.41,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,24.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.41,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,24.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,24.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,24.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.41,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,24.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,24.72,43.41,
EDP EXPL PENETRATING WND ABD/FLANK/BACK,12020102,CDM,981,RC,20103,HCPCS,Outpatient,,,682,682,,,,,,Other,Not Separately Reimbursable,135.39,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,135.39,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.94,135.39,
EDP EXPLORATION PENETRATING WOUND/EXTREM,12020103,CDM,981,RC,20520,HCPCS,Outpatient,,,919,919,,,,,,Other,Not Separately Reimbursable,363.27,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,363.27,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,235.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,409.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,235.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,409.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,235.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,235.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,235.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,409.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,235.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,235.37,409.31,
EDP REM FOREIGN BODY MUSCLE/TEND;SIMPLE,12020520,CDM,981,RC,20552,HCPCS,Outpatient,,,162,162,,,,,,Other,Not Separately Reimbursable,226.34,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,226.34,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,170.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,170.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,170.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.38,226.34,
INJ SINGLE/MULT TRIG POINT(S) 1 OR 2 MUS,12020552,CDM,981,RC,21480,HCPCS,Outpatient,,,108,108,,,,,,Other,Not Separately Reimbursable,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.61,63.31,
EDP CLSD TRMT TEMPOROMANDIBLULAR DISLOCA,12021480,CDM,983,RC,23625,HCPCS,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,75.96,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,75.96,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,21,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,37.88,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,21,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,37.88,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,21,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,21,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,21,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,37.88,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,21,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,21,75.96,
EDP CLOSED TX GRETER HUMERAL TUBEROSITY,12023625,CDM,981,RC,25505,HCPCS,Outpatient,,,915,915,,,,,,Other,Not Separately Reimbursable,402.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,402.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,242.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,425.57,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,242.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,425.57,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,242.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,242.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,242.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,425.57,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,242.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,242.01,425.57,
CLSD TRMT OF RADIAL SHAFT FX W/MANIPULAT,12025505,CDM,981,RC,25605,HCPCS,Outpatient,,,1309,1309,,,,,,Other,Not Separately Reimbursable,467.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,467.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,316.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,550.72,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,316.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,550.72,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,316.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,316.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,316.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,550.72,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,316.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,316.22,550.72,
EDP CLSD TRMT DISTAL RDL FX W/MANIPULATI,12025605,CDM,981,RC,26010,HCPCS,Outpatient,,,1471,1471,,,,,,Other,Not Separately Reimbursable,511.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,511.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,352.59,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,612.06,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,352.59,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,612.06,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,352.59,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,352.59,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,352.59,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,612.06,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,352.59,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,352.59,612.06,
"EDP DRAINAGE OF FINGER ABCESS, SIMPLE",12026010,CDM,981,RC,26011,HCPCS,Outpatient,,,393,393,,,,,,Other,Not Separately Reimbursable,201.34,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,201.34,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,95.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,164.77,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,95.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,164.77,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,95.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,95.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,95.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,164.77,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,95.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,95.03,201.34,
"EDP DRAINAGE OF FINGER ABCESS, COMPLEX",12026011,CDM,981,RC,26605,HCPCS,Outpatient,,,481,481,,,,,,Other,Not Separately Reimbursable,294.08,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,294.08,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,127.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,218.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,218.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,127.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,127.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,218.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,127.14,294.08,
EDP CLSD TRMT OF METACARPAL FX W/MANIP,12026605,CDM,981,RC,26725,HCPCS,Outpatient,,,835,835,,,,,,Other,Not Separately Reimbursable,305.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,305.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,202.27,354.55,
EDP CLSD TRMT W/MANIPUL W/WO SKIN/SKEL T,12026725,CDM,981,RC,26742,HCPCS,Outpatient,,,868,868,,,,,,Other,Not Separately Reimbursable,291.54,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,291.54,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,208.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,364.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,208.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,364.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,208.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,208.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,208.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,364.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,208.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,208.98,364.71,
CLOSED TRT ART FRACT W/MANIPULATION,12026742,CDM,981,RC,27372,HCPCS,Outpatient,,,777,777,,,,,,Other,Not Separately Reimbursable,378.04,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,378.04,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,230.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,403.06,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,230.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,403.06,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,230.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,230.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,230.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,403.06,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,230.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,230.76,403.06,
"EDP REM OF FOEIGN BODY, DEEP THIGH/KNEE",12027372,CDM,981,RC,27788,HCPCS,Outpatient,,,939,939,,,,,,Other,Not Separately Reimbursable,477.82,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,477.82,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,276.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,476.17,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,276.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,476.17,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,276.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,276.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,276.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,476.17,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,276.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,276.1,477.82,
EDP TX FX/DISLOCATION LOWER LEG/ANKLE,12027788,CDM,981,RC,28190,HCPCS,Outpatient,,,1005,1005,,,,,,Other,Not Separately Reimbursable,402.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,402.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,265.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,460.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,265.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,460.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,265.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,265.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,265.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,460.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,265.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,265.7,460.46,
"REMOVAL OF FOREIGN BODY,FOOT;SUBCUTANEOU",12028190,CDM,981,RC,28495,HCPCS,Outpatient,,,379,379,,,,,,Other,Not Separately Reimbursable,232.13,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,232.13,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,89.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,152.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,89.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,152.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,89.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,89.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,89.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,152.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,89.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,89.76,232.13,
"EDP ER CLSD TRMT FX TOE,PHALANX,PHALANGE",12028495,CDM,981,RC,28660,HCPCS,Outpatient,,,334,334,,,,,,Other,Not Separately Reimbursable,149.15,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,149.15,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.74,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.74,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.74,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.74,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,100.74,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.74,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.74,172.55,
"EDP TX CL INTERPALANGEAL JNT DIS, W/O AN",12028660,CDM,981,RC,31238,HCPCS,Outpatient,,,230,230,,,,,,Other,Not Separately Reimbursable,135.39,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,135.39,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,109.94,135.39,
"EDP NASAL/SINUS ENDOSCOPY,SURGICAL;W/BIO",12031238,CDM,981,RC,31605,HCPCS,Outpatient,,,535,535,,,,,,Other,Not Separately Reimbursable,265.61,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,265.61,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,112.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,196.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,112.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,196.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,112.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,112.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,112.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,196.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,112.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,112.63,265.61,
EDP TRACHEOSTOMY EMER CRICOTHYROID MEMBR,12031605,CDM,981,RC,37609,HCPCS,Outpatient,,,519,519,,,,,,Other,Not Separately Reimbursable,224.17,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,224.17,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,156.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,401.4,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,156.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,401.4,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,156.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,156.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,156.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,401.4,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,156.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,156.85,401.4,
"EDP LIGATION OR BIOPSY, TEMPORAL ARTERY",12037609,CDM,981,RC,40800,HCPCS,Outpatient,,,491,491,,,,,,Other,Not Separately Reimbursable,286.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,286.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,139.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,243.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,139.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,243.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,139.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,139.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,139.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,243.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,139.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,139.61,286.42,
EDP DRAINAGE OF ABSCESS IN MOUTH-SIMPLE,12040800,CDM,983,RC,40804,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,107.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,107.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.76,134.94,
EDP REM OF EMBED FOREIGN BODY VEST MOUTH,12040804,CDM,983,RC,41017,HCPCS,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,126.08,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,126.08,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,76.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,130.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,76.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,130.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,76.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,76.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,76.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,130.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,76.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,76.15,130.24,
"EDP EXTRAORAL I & D, SUBMANDIBULAR",12041017,CDM,981,RC,41252,HCPCS,Outpatient,,,824,824,,,,,,Other,Not Separately Reimbursable,290.87,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,290.87,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,233.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,395.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,233.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,395.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,233.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,233.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,233.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,395.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,233.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,233.06,395.13,
"REP OF LAC TONGUE, MOUTH FLOOR >26CM COM",12041252,CDM,981,RC,41800,HCPCS,Outpatient,,,617,617,,,,,,Other,Not Separately Reimbursable,242.47,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,242.47,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,142.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,246.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,142.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,246.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,142.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,142.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,142.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,246.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,142.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,142.13,246.86,
EDP DRAINAGE ABSCESS/CYST/HEMA - DENTOAL,12041800,CDM,981,RC,43762,HCPCS,Outpatient,,,195,195,,,,,,Other,Not Separately Reimbursable,106.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,106.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,104.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,176.58,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,176.58,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,104.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,104.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,176.58,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,104.61,176.58,
EDP REPL GAST TUBE PERCUT W/O IMAG/REVIS,12043762,CDM,981,RC,46050,HCPCS,Outpatient,,,496,496,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,44.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,44.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,44.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.15,44.07,
"EDP I & D, PERIANAL ABSCESS SUPERFICIAL",12046050,CDM,981,RC,46083,HCPCS,Outpatient,,,280,280,,,,,,Other,Not Separately Reimbursable,147.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,147.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,68.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,119.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,119.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,68.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,119.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.22,147.67,
"EDP INCISION OF THROMBOSED HEMM, EXTERN",12046083,CDM,983,RC,49082,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,184.62,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,184.62,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,74.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,74.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,74.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,74.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,74.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,74.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,74.92,184.62,
EDP ABDOMINAL PARACENTESIS W/OIMAGING GU,12049082,CDM,981,RC,49083,HCPCS,Outpatient,,,174,174,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,49.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,85.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,85.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,49.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,85.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.68,85.8,
EDP ABDOMINAL PARACENTESIS W/IMAGING GUI,12049083,CDM,981,RC,49440,HCPCS,Outpatient,,,251,251,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,71.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.53,122.75,
"EDP INTERSTION GASTROSTOMY TUBE, PERCUTA",12049440,CDM,981,RC,51705,HCPCS,Outpatient,,,619,619,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,136.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,235.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,136.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,235.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,136.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,136.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,136.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,235.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,136.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,136.13,235.31,
CHANGE OF CYSTOSTOMY TUBE;SIMPLE,12051705,CDM,981,RC,55100,HCPCS,Outpatient,,,145,145,,,,,,Other,Not Separately Reimbursable,111.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,111.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,59.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,59.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,59.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.61,111.31,
DRAINAGE OF SCROTAL WALL ABCESS,12055100,CDM,981,RC,56405,HCPCS,Outpatient,,,467,467,,,,,,Other,Not Separately Reimbursable,338.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,338.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,113.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,195.12,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,113.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,195.12,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,113.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,113.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,113.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,195.12,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,113.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,113.53,338.33,
EDP I&D PERINEAL ABSCESS,12056405,CDM,981,RC,57000,HCPCS,Outpatient,,,291,291,,,,,,Other,Not Separately Reimbursable,130.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,130.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,82.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,148.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,148.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,82.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,82.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,148.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,82.1,148.75,
EDP COLPOTOMY W/ EXPLORATION,12057000,CDM,981,RC,62322,HCPCS,Outpatient,,,694,694,,,,,,Other,Not Separately Reimbursable,206.19,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,206.19,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,137.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,240.1,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,137.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,240.1,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,137.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,137.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,137.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,240.1,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,137.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,137.68,240.1,
Injection of substance into spinal canal of lower back or sacrum using imaging guidance,12062322,CDM,981,RC,64402,HCPCS,Outpatient,,,254,254,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,54.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,54.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,54.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,54.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,54.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.92,94.39,
"EDP N BLOCK INJ, FACIAL",12064402,CDM,981,RC,67700,HCPCS,Outpatient,,,194,194,,,,,,Other,Not Separately Reimbursable,162.41,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,162.41,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,162.41,162.41,
"EDP BLEPHAROTOMY, ABSCESS DRAINAGE, EYEL",12067700,CDM,981,RC,67840,HCPCS,Outpatient,,,298,298,,,,,,Other,Not Separately Reimbursable,202.6,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,202.6,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,77.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,131.11,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,131.11,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,77.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,77.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,131.11,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,77.53,202.6,
EDP EXCISION LESION EYELID W/O CLOSURE,12067840,CDM,981,RC,69000,HCPCS,Outpatient,,,360,360,,,,,,Other,Not Separately Reimbursable,248.9,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,248.9,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,178.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,178.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,178.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.22,248.9,
"EDP DRAINAGE EXTERNAL EAR, ABSCESS/HEMAT",12069000,CDM,981,RC,69209,HCPCS,Outpatient,,,314,314,,,,,,Other,Not Separately Reimbursable,118.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,118.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,83.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,145.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,83.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,145.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,83.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,83.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,83.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,145.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,83.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,83.06,145.26,
EDP REMOVAL IMPACT CERUMEN USING IRRIG/L,12069209,CDM,981,RC,93010,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9.96,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,17.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,9.96,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,17.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,9.96,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,9.96,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,9.96,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,17.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,9.96,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,9.96,17.04,
EDP EKG INTERPRETATION & REPORT,12093010,CDM,985,RC,97597,HCPCS,Outpatient,,,18,18,,,,,,Other,Not Separately Reimbursable,10.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,10.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,9.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,9.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,9.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,5.76,10.46,
"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",12097597,CDM,981,RC,190,HCPCS,Outpatient,,,94,94,,,,,,Other,Not Separately Reimbursable,48.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,48.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,41.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,18.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,41.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,18.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,18.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,18.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,41.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,18.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,18.12,48.03,
ANES - FACIAL BONES OR SKULL,17000019,CDM,964,RC,100,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - SALIVARY GLANDS W/BIOPSY,17000100,CDM,964,RC,120,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
"ANES - EXT, MID, & INNER EAR W/BIOPSY",17000120,CDM,964,RC,124,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - OTOSCOPY,17000124,CDM,964,RC,126,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - TYMPANOTOMY,17000126,CDM,964,RC,140,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - EYES; NOT OTHERWISE SPECIFIED,17000140,CDM,964,RC,160,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
"ANES - NOSE,ACCESS SINUS NOT SPEC",17000160,CDM,964,RC,1630,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - SHOULDER ARTHROSCOPY,17000163,CDM,964,RC,164,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
"ANES - BIOSPY, SOFT TISSUE",17000164,CDM,964,RC,170,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - INTRAORAL PROC W/BIO NOT SPEC,17000170,CDM,964,RC,174,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - EXC RETROPHARYNGEAL TUMOR,17000174,CDM,964,RC,190,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - FACIAL BONES OR SKULL,17000190,CDM,964,RC,212,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - SUBDURAL TAPS,17000212,CDM,964,RC,300,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - INTEGUMENTARY SYS/MUS/NRVS NECK,17000300,CDM,964,RC,320,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - ESO/THY/SYS NECK >1 YR,17000320,CDM,964,RC,326,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - LARYNX/TRACHEA <1 YR,17000326,CDM,964,RC,400,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - INTEGUMENTARY SYSTEM EXT/A TRK/PE,17000400,CDM,964,RC,404,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - RADICAL/MOD RADICAL PROC BREAST,17000404,CDM,964,RC,524,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - PNEUMOCENTESIS,17000524,CDM,964,RC,532,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - ACCESS CENT VENOUS CIRCULATION,17000532,CDM,964,RC,600,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - CERICVAL SPINE & CORD;NOS,17000600,CDM,964,RC,620,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - THORACIC SPINE AND CORD,17000620,CDM,964,RC,630,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES- LUMBAR REGION,17000630,CDM,964,RC,700,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - UPPER ANTER ABD WALL NOT SPEC,17000700,CDM,964,RC,730,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - UPPER POST ABD WALL,17000730,CDM,964,RC,731,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - UPPER GAS/ENDO PROXIMAL DUODENDUM,17000731,CDM,964,RC,732,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - UPPER GAS/ENDOSCOPIC RETROGRADE C,17000732,CDM,964,RC,750,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - HERNIA REPAIRS UPPER ABD,17000750,CDM,964,RC,752,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - LUMB/VENT HERNIA/WND DEHISCENCE,17000752,CDM,964,RC,790,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - INTRAPERITONEAL UP ABD W/LAP NOT,17000790,CDM,964,RC,800,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - LOWER ANTERIOR ABD WALL NOT SPEC,17000800,CDM,964,RC,811,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - LOWER INTEST ENDO INTO DISTAL DUO,17000811,CDM,964,RC,812,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - LOWER INTEST ENDO-SCREENING COLON,17000812,CDM,964,RC,813,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - COMBINED UPPER/LOWER INTEST ENDO,17000813,CDM,964,RC,820,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - LOWER POST ABD WALL,17000820,CDM,964,RC,830,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - HERNIA REPAIRS LOWER ABD NOT SPEC,17000830,CDM,964,RC,832,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - VERNATL/INCISIONAL HERNIAS,17000832,CDM,964,RC,840,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - INTRAPERITONEAL LOW ABD W/LAP NOT,17000840,CDM,964,RC,846,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - RADICAL HYSTERECTOMY,17000846,CDM,964,RC,851,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - TUBAL LIGATION/TRANSECTION,17000851,CDM,964,RC,860,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - EXTRAPERITONEAL LOWER ABD INC URI,17000860,CDM,964,RC,866,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - ADRENALECTOMY,17000866,CDM,964,RC,902,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - ANORECTAL PROC,17000902,CDM,964,RC,910,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - TRANSURETHRAL PROC INC URETHROCYS,17000910,CDM,964,RC,920,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
"ANES - MALE GENITALIA, INC OPEN URETHRAL",17000920,CDM,964,RC,921,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - VASECTOMY UNILATERAL OR BILATERAL,17000921,CDM,964,RC,940,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
"ANES - VAGINAL PROC INCLUDES BIOPSY, NOT",17000940,CDM,964,RC,942,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
"ANES - VAGINAL, OPEN URETHAL PROCEDURES",17000942,CDM,964,RC,944,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
"ANES - VAGINAL, HYSTERECTOMY",17000944,CDM,964,RC,952,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - HYSTEROSCOPY,17000952,CDM,964,RC,,,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANESTHESIA PROFEE PER MINUTE,17001000,CDM,964,RC,1120,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - PROCEDURES ON BONY PELVIS,17001120,CDM,964,RC,1232,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - AMPUTATION,17001232,CDM,964,RC,1380,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - ALL CLOSED PROCED ON KNEE JNT,17001380,CDM,964,RC,1382,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - DIAG ARTHROSCOPIC PROC KNEE JOINT,17001382,CDM,964,RC,1400,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - OPEN/SURGICAL ARTHROSCOPIC KNEE,17001400,CDM,964,RC,1462,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
"ANES-ALL CLSD PROC ON LOWER LEG, ANK, FT",17001462,CDM,964,RC,1470,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - PROC NERV/MUSC/TEN/FAC LOW LEG,17001470,CDM,964,RC,1474,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - GASTROCNEMIUS RECESSION(STRAYER),17001474,CDM,964,RC,1480,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - PRC BONES OF LOW LEG/ANKLE/FT,17001480,CDM,964,RC,1482,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - RADICAL RESECTION(INC BKAMPUT),17001482,CDM,964,RC,1610,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
"ANES - SHOULD/AXILLA NERVES, MUSC, TENDO",17001610,CDM,964,RC,1810,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - NERVES/MUSC/TEND/FASCIA/F/W/H,17001810,CDM,964,RC,1830,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - ORIF HAND,17001830,CDM,964,RC,1935,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - IMAGE GUIDED PROC SPINE & CORD DI,17001935,CDM,964,RC,1951,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
"ANES - 2,3 BURN E/D W/WO SKIN GRAFT <4%",17001951,CDM,964,RC,1952,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
"ANES - 2,3 BURN 4-9% BODY SURFACE AREA",17001952,CDM,964,RC,1953,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - ADD 9% BODY SURFACE AREA OR PART,17001953,CDM,964,RC,630,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
"ANES- PRC LUMBAR REGION, NOT SPECIFIE",17006300,CDM,964,RC,64450,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - NERVE BLK OTH PERIPH NERV OR BRAN,17064450,CDM,964,RC,99100,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - PT OF EXT AGE; <1YO OR >70,17099100,CDM,964,RC,99149,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - MOD SED >5 YRS FIRST 30 MINUTES,17099149,CDM,964,RC,99152,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES-MOD SED >5 YRS FIRST 15 MINUTES,17099152,CDM,964,RC,99153,HCPCS,Outpatient,,,180,180,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - MOD SED >5 YRS FIRST 15 MINUTES,17099153,CDM,964,RC,99155,HCPCS,Outpatient,,,25,25,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - MOD SED <5 YRS FIRST 30 MINUTES,17099155,CDM,964,RC,99156,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - MOD SED >5 YRS FIRST 30 MINUTES,17099156,CDM,964,RC,99157,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - ADDITIONAL 15 MINUTES,17099157,CDM,964,RC,99100,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - PT OF EXT AGE <1YO OR >70 HEALTHY,17199100,CDM,964,RC,99100,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - PT OF EXT AGE <1Y OR >70 MSYS DIS,17299100,CDM,964,RC,99100,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - PT OF EXT AGE <1Y OR >70 SSYS DIS,17399100,CDM,964,RC,99100,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - PT OF EXT AGE <1Y OR >70 DIS LIFE,17499100,CDM,964,RC,99100,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - PT OF EXT AGE <1Y OR >70 P5,17599100,CDM,964,RC,99100,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - PT OF EXT AGE <1Y OR >70 ORG DON,17699100,CDM,964,RC,99100,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - PT OF EXT AGE <1Y OR >70 UNUS ANE,17799100,CDM,964,RC,99100,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
ANES - PT OF EXT AGE <1Y OR >70 DIST PRO,17899100,CDM,964,RC,36580,HCPCS,Outpatient,,,12,12,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
REPLACE CENTRAL LINE SAME SITE,36736580,CDM,983,RC,12053,HCPCS,Outpatient,,,135,135,,,,,,Other,Not Separately Reimbursable,301.72,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,301.72,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,44.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,77.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,44.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,77.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,44.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,44.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,44.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,77.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,44.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,44.3,301.72,
INTERMEDIATE WOUND REPAIR/FACE 5.1-7.5CM,67012053,CDM,983,RC,12054,HCPCS,Outpatient,,,243,243,,,,,,Other,Not Separately Reimbursable,229.55,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,229.55,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,250.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,250.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,250.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,144.44,250.02,
INTER WOUND REPAIR/FACE 7.6-12.5CM,67012054,CDM,983,RC,12055,HCPCS,Outpatient,,,249,249,,,,,,Other,Not Separately Reimbursable,261.74,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,261.74,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,258.51,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,258.51,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,258.51,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,147.91,261.74,
INTER WOUND REPAIR/FACE 12.6-20.0CM,67012055,CDM,983,RC,12056,HCPCS,Outpatient,,,339,339,,,,,,Other,Not Separately Reimbursable,341.29,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,341.29,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,202.37,354.34,
INTER WOUND REPAIR/FACE 20.1-30.0CM,67012056,CDM,983,RC,12057,HCPCS,Outpatient,,,429,429,,,,,,Other,Not Separately Reimbursable,445.4,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,445.4,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,451.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,451.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,451.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,261.2,451.48,
INTER WOUND REPAIR/FACE >30.0CM,67012057,CDM,983,RC,13100,HCPCS,Outpatient,,,481,481,,,,,,Other,Not Separately Reimbursable,479.71,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,479.71,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,284.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,493.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,284.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,493.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,284.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,284.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,284.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,493.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,284.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,284.75,493.43,
COMPLEX WOUND REPAIR/TRUNK 1.1-2.5CM,67013100,CDM,983,RC,13101,HCPCS,Outpatient,,,230,230,,,,,,Other,Not Separately Reimbursable,230.77,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,230.77,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.99,232.33,
COMPLEX WOUND REPAIR/TRUNK 2.6-7.5CM,67013101,CDM,983,RC,13102,HCPCS,Outpatient,,,282,282,,,,,,Other,Not Separately Reimbursable,277.05,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,277.05,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,167.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,285.22,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,167.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,285.22,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,167.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,167.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,167.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,285.22,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,167.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,167.3,285.22,
COMPLEX WOUND REPAIR/TRUNK EA ADD <5CM,67013102,CDM,983,RC,13120,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,78.02,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,78.02,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,48.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,84.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,48.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,84.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,48.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,48.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,84.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,48.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.92,84.34,
COMPLEX WOUND REPAIR/EXTREMITY 1.1-2.5CM,67013120,CDM,983,RC,20205,HCPCS,Outpatient,,,263,263,,,,,,Other,Not Separately Reimbursable,243.55,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,243.55,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,157.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,267.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,157.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,267.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,157.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,157.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,157.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,267.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,157.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,157.37,267.9,
MUSCLE BIOPSY DEEP,67020205,CDM,983,RC,20520,HCPCS,Outpatient,,,179,179,,,,,,Other,Not Separately Reimbursable,213.55,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,213.55,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,104.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,104.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,104.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,104.99,213.55,
REMOVAL OF FOREIGN BODY IN MUSCLE OR TEN,67020520,CDM,983,RC,20610,HCPCS,Outpatient,,,162,162,,,,,,Other,Not Separately Reimbursable,226.34,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,226.34,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,170.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,170.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,170.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.38,226.34,
Draining or injecting medication into a major joint/bursa without ultrasound,67020610,CDM,983,RC,20612,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,94.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,94.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.69,94.3,
Removal of fluid or injection of medication into a ganglion cyst,67020612,CDM,983,RC,27327,HCPCS,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,56.98,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,56.98,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,27.92,56.98,
EXCISION OF TUMOR SUBCUTANEOUS,67027327,CDM,983,RC,40800,HCPCS,Outpatient,,,351,351,,,,,,Other,Not Separately Reimbursable,435.36,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,435.36,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,215.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,373.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,215.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,373.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,215.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,215.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,215.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,373.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,215.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,215.01,435.36,
DRAINAGE OF ABSCESS IN MOUTH-SIMPLE,67040800,CDM,983,RC,46230,HCPCS,Outpatient,,,145,145,,,,,,Other,Not Separately Reimbursable,107.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,107.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.76,134.94,
HEMORROID TAG REMOVAL,67046230,CDM,983,RC,46320,HCPCS,Outpatient,,,195,195,,,,,,Other,Not Separately Reimbursable,224.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,224.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,117.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,204.63,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,117.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,204.63,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,117.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,117.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,117.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,204.63,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,117.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,117.91,224.52,
"EXCISION OF THROMBOSED HEMORRHOID, EXTER",67046320,CDM,983,RC,99200,HCPCS,Outpatient,,,124,124,,,,,,Other,Not Separately Reimbursable,172.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,172.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,133.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,133.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,133.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,77.08,172.43,
OFFICE VISIT 10 MIN NEW,67699201,CDM,983,RC,99200,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 20 MIN NEW,67699202,CDM,983,RC,99200,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 30 MIN NEW,67699203,CDM,983,RC,99200,HCPCS,Outpatient,,,91,91,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 45 MIN NEW,67699204,CDM,983,RC,99200,HCPCS,Outpatient,,,153,153,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 60 MIN NEW,67699205,CDM,983,RC,99200,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 5 MIN EST,67699211,CDM,983,RC,99200,HCPCS,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 10 MIN EST,67699212,CDM,983,RC,99200,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 15 MIN EST,67699213,CDM,983,RC,99200,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 25 MIN EST,67699214,CDM,983,RC,99200,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 40 MIN EST,67699215,CDM,983,RC,99201,HCPCS,Outpatient,,,131,131,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 10 MIN NEW,67799201,CDM,983,RC,99202,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 20 MIN NEW,67799202,CDM,983,RC,99203,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 30 MIN NEW,67799203,CDM,983,RC,99204,HCPCS,Outpatient,,,91,91,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 45 MIN NEW,67799204,CDM,983,RC,99205,HCPCS,Outpatient,,,153,153,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 60 MIN NEW,67799205,CDM,983,RC,99211,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 5 MIN EST,67799211,CDM,983,RC,99212,HCPCS,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 10 MIN EST,67799212,CDM,983,RC,99213,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 15 MIN EST,67799213,CDM,983,RC,99214,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 25 MIN EST,67799214,CDM,983,RC,99215,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 40 MIN EST,67799215,CDM,983,RC,99201,HCPCS,Outpatient,,,131,131,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 10 MIN NEW,67899201,CDM,983,RC,99202,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 20 MIN NEW,67899202,CDM,983,RC,99203,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 30 MIN NEW,67899203,CDM,983,RC,99204,HCPCS,Outpatient,,,91,91,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 45 MIN NEW,67899204,CDM,983,RC,99205,HCPCS,Outpatient,,,153,153,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 60 MIN NEW,67899205,CDM,983,RC,99211,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 5 MIN EST,67899211,CDM,983,RC,99212,HCPCS,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 10 MIN EST,67899212,CDM,983,RC,99213,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 15 MIN EST,67899213,CDM,983,RC,99214,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 25 MIN EST,67899214,CDM,983,RC,99215,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 40 MIN EST,67899215,CDM,983,RC,G0179,HCPCS,Outpatient,,,131,131,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
PHY RECERT FOR MCR COVERED HH SVCS,67900179,CDM,983,RC,G0180,HCPCS,Outpatient,,,93,93,,,,,,Other,Not Separately Reimbursable,59.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,59.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,59.25,
PHY CERTIFICATION FOR MCR COVD HH SVCS,67900180,CDM,983,RC,G2012,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,70.72,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,70.72,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.13,70.72,
VIRTUAL CK IN; BRIEF 5-10 MIN,67902012,CDM,983,RC,10021,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.54,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.54,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.54,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.54,14.54,
Fine Needle Aspiration Biopsy without imaging,67910021,CDM,983,RC,10060,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,89.29,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,89.29,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.92,89.29,
Incision and drainage of abscess; simple or single and complex or multiple,67910060,CDM,983,RC,10061,HCPCS,Outpatient,,,116,116,,,,,,Other,Not Separately Reimbursable,87.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,87.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.7,120.26,
I&D ABSCESS COMPLEX,67910061,CDM,983,RC,10080,HCPCS,Outpatient,,,213,213,,,,,,Other,Not Separately Reimbursable,158.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,158.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.29,212.07,
I&D CYST SIMPLE,67910080,CDM,983,RC,10081,HCPCS,Outpatient,,,122,122,,,,,,Other,Not Separately Reimbursable,107.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,107.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,70.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.92,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.92,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,70.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.92,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.62,120.92,
I&D CYST COMPLEX,67910081,CDM,983,RC,10120,HCPCS,Outpatient,,,204,204,,,,,,Other,Not Separately Reimbursable,187.04,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,187.04,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,116.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,201.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,116.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,201.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,116.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,116.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,116.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,201.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,116.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,116.53,201.42,
I&D RMV FB SIMPLE,67910120,CDM,983,RC,10121,HCPCS,Outpatient,,,123,123,,,,,,Other,Not Separately Reimbursable,102.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,102.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,121.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,121.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,121.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.15,121.26,
I&D RMV FB COMPLEX,67910121,CDM,983,RC,10140,HCPCS,Outpatient,,,222,222,,,,,,Other,Not Separately Reimbursable,196.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,196.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,214.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,214.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,214.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.84,214.35,
"Incision and drainage of hematoma, seroma or fluid collection",67910140,CDM,983,RC,10160,HCPCS,Outpatient,,,142,142,,,,,,Other,Not Separately Reimbursable,106.54,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,106.54,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,80.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,136.25,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,136.25,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,80.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,136.25,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.06,136.25,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",67910160,CDM,983,RC,10180,HCPCS,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,94.05,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,94.05,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.38,111.8,
I&D POST-OP WOUND INFECTION,67910180,CDM,983,RC,11000,HCPCS,Outpatient,,,216,216,,,,,,Other,Not Separately Reimbursable,146.32,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,146.32,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,121.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,211.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,121.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,211.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,121.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,121.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,121.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,211.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,121.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,121.38,211.14,
Removal of infected skin,67911000,CDM,983,RC,11004,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,43.7,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,43.7,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,31.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,18.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,31.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,18.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,18.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,18.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,31.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,18.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,18.69,43.7,
DEBRIDE GENITALS & PERINEUM,67911004,CDM,983,RC,11011,HCPCS,Outpatient,,,713,713,,,,,,Other,Not Separately Reimbursable,559.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,559.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,402.93,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,681.29,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,402.93,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,681.29,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,402.93,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,402.93,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,402.93,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,681.29,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,402.93,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,402.93,681.29,
"DEBRIDE SKIN/MUSCLE, FX",67911011,CDM,983,RC,11042,HCPCS,Outpatient,,,369,369,,,,,,Other,Not Separately Reimbursable,363.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,363.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,201.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,352.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,201.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,352.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,201.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,201.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,201.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,352.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,201.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,201.45,363.09,
DEBRIDE SKIN/TISSUE,67911042,CDM,983,RC,11043,HCPCS,Outpatient,,,74,74,,,,,,Other,Not Separately Reimbursable,78.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,78.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.61,78.03,
DEBRIDE TISSUE/MUSCLE,67911043,CDM,983,RC,11044,HCPCS,Outpatient,,,188,188,,,,,,Other,Not Separately Reimbursable,189.08,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,189.08,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,104.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,180.95,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,180.95,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,104.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,104.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,180.95,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,104.07,189.08,
DEBRIDE BONE FIRST 20 SQCM OR LESS,67911044,CDM,983,RC,11046,HCPCS,Outpatient,,,281,281,,,,,,Other,Not Separately Reimbursable,243.32,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,243.32,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,152.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,266.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,152.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,266.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,152.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,152.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,152.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,266.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,152.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,152.3,266.86,
WND DEBRID(TISSUE& MUSCLE)EA ADDL 20SQCM,67911046,CDM,983,RC,11055,HCPCS,Outpatient,,,69,69,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,65.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,65.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,65.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,37.61,65.53,
TRIM SKIN LESION SINGLE,67911055,CDM,983,RC,11200,HCPCS,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,23.02,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,23.02,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,10.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,18.83,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,10.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,18.83,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,10.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,10.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,10.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,18.83,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,10.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,10.85,23.02,
"Removal of skin tags, multiple fibrocutaneous tags, any area",67911200,CDM,983,RC,11201,HCPCS,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,64.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,64.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,50.27,87.42,
RMV SKIN TAGS ADD-ON,67911201,CDM,983,RC,11400,HCPCS,Outpatient,,,21,21,,,,,,Other,Not Separately Reimbursable,26.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,26.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,19.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,11.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,19.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,11.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,11.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,11.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,19.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,11.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,11.08,26.3,
EXC-BENIGN TRUNK/ARM/LEGS <0.5 CM,67911400,CDM,983,RC,11401,HCPCS,Outpatient,,,96,96,,,,,,Other,Not Separately Reimbursable,107.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,107.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.77,107.57,
Under Excision-Benign Lesions Procedures on the Skin 0.6-1 CM,67911401,CDM,983,RC,11402,HCPCS,Outpatient,,,124,124,,,,,,Other,Not Separately Reimbursable,126.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,126.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.84,126.52,
EXC-BENIGN TRUNK/ARM/LEGS 1.1-2.0 CM,67911402,CDM,983,RC,11403,HCPCS,Outpatient,,,137,137,,,,,,Other,Not Separately Reimbursable,143.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,143.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,133.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,133.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,133.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,78.28,143.18,
EXC-BENIGN TRUNK/ARM/LEGS 2.1-3.0 CM,67911403,CDM,983,RC,11404,HCPCS,Outpatient,,,178,178,,,,,,Other,Not Separately Reimbursable,166.14,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,166.14,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.38,172.68,
EXC-BENIGN TRUNK/ARM/LEGS 3.1-4.0 CM,67911404,CDM,983,RC,11406,HCPCS,Outpatient,,,196,196,,,,,,Other,Not Separately Reimbursable,183.74,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,183.74,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,191.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,191.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,191.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111,191.76,
EXCIS BENIGN LES TRUNK/ARMS/LEGS>4.0CM,67911406,CDM,983,RC,11420,HCPCS,Outpatient,,,300,300,,,,,,Other,Not Separately Reimbursable,220.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,220.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,291.88,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,291.88,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,291.88,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,168.68,291.88,
EXC-BENIGN SP/NK/H/F/G <0.5 CM,67911420,CDM,983,RC,11421,HCPCS,Outpatient,,,96,96,,,,,,Other,Not Separately Reimbursable,103.65,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,103.65,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.61,103.65,
EXC-BENIGN SP/NK/H/F/G 0.6-1.0 CM,67911421,CDM,983,RC,11422,HCPCS,Outpatient,,,131,131,,,,,,Other,Not Separately Reimbursable,133.54,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,133.54,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,73.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,126.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,73.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,126.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,73.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,73.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,73.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,126.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,73.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,73.84,133.54,
Under Excision-Benign Lesions Procedures on the Skin 1.1-2 CM,67911422,CDM,983,RC,11423,HCPCS,Outpatient,,,163,163,,,,,,Other,Not Separately Reimbursable,149.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,149.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,91.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,156.66,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,91.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,156.66,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,91.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,91.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,91.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,156.66,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,91.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,91.61,156.66,
EXC-BENIGN SP/NK/H/F/G 2.1-3.0 CM,67911423,CDM,983,RC,11424,HCPCS,Outpatient,,,188,188,,,,,,Other,Not Separately Reimbursable,181.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,181.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,180.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,180.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,180.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.22,181.76,
EXC-BENIGN SP/NK/H/F/G 3.1-4.0 CM,67911424,CDM,983,RC,11426,HCPCS,Outpatient,,,216,216,,,,,,Other,Not Separately Reimbursable,205.96,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,205.96,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,120.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,207.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,120.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,207.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,120.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,120.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,207.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,120.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.22,207.64,
EXC H-F-NK-SP B9+MARG >4CM,67911426,CDM,983,RC,11440,HCPCS,Outpatient,,,335,335,,,,,,Other,Not Separately Reimbursable,277.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,277.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,184.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,317.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,184.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,317.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,184.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,184.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,184.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,317.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,184.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,184.6,317.02,
EXC BENIGN FACE/EARS/ETC .5CM OR <,67911440,CDM,983,RC,11441,HCPCS,Outpatient,,,122,122,,,,,,Other,Not Separately Reimbursable,123.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,123.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,70.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,70.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.38,123.67,
EXC-BENIGN FACE/EARS/ETC 0.6-1.0 CM,67911441,CDM,983,RC,11442,HCPCS,Outpatient,,,156,156,,,,,,Other,Not Separately Reimbursable,147.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,147.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,89.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,152.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,89.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,152.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,89.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,89.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,89.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,152.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,89.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,89.08,152.79,
EXC BENIGN FACE/EARS/ETC 1.1-2.0 CM,67911442,CDM,983,RC,11443,HCPCS,Outpatient,,,173,173,,,,,,Other,Not Separately Reimbursable,163.65,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,163.65,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,98.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,169.17,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,98.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,169.17,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,98.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,98.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,98.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,169.17,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,98.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,98.41,169.17,
EXC-BENIGN FACE/EARS/ETC 2.1-3.0 CM,67911443,CDM,983,RC,11444,HCPCS,Outpatient,,,213,213,,,,,,Other,Not Separately Reimbursable,206.87,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,206.87,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,120.79,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,206.89,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,120.79,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,206.89,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,120.79,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.79,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,120.79,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,206.89,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,120.79,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.79,206.89,
EXC-BENIGN FACE/EARS/ETC 3.1-4.0 CM,67911444,CDM,983,RC,11446,HCPCS,Outpatient,,,273,273,,,,,,Other,Not Separately Reimbursable,256.99,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,256.99,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,152.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,262.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,152.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,262.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,152.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,152.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,152.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,262.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,152.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,152.99,262.38,
EXCISION OF BENIGN LESION >4CM,67911446,CDM,983,RC,11450,HCPCS,Outpatient,,,392,392,,,,,,Other,Not Separately Reimbursable,314.96,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,314.96,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,216.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,368.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,216.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,368.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,216.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,216.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,216.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,368.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,216.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,216.68,368.87,
"EXC- OF AX, HIDRAD-SIMPLE",67911450,CDM,983,RC,11451,HCPCS,Outpatient,,,308,308,,,,,,Other,Not Separately Reimbursable,249.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,249.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,176.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,309.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,176.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,309.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,176.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,176.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,176.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,309.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,176.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,176.18,309.82,
HIDRADENITIS EXCISION W/COMPLEX REPAIR,67911451,CDM,983,RC,11462,HCPCS,Outpatient,,,395,395,,,,,,Other,Not Separately Reimbursable,328.27,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,328.27,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,225.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,393.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,225.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,393.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,225.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,225.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,225.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,393.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,225.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,225.25,393.56,
EXCISION OF INGUINAL HIDRAD-SIMPLE,67911462,CDM,983,RC,11600,HCPCS,Outpatient,,,293,293,,,,,,Other,Not Separately Reimbursable,239.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,239.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,167.81,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,292.49,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,167.81,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,292.49,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,167.81,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,167.81,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,167.81,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,292.49,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,167.81,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,167.81,292.49,
EXC-MALIG TRUNK/ARMS/LEGS <0.5 CM,67911600,CDM,983,RC,11601,HCPCS,Outpatient,,,144,144,,,,,,Other,Not Separately Reimbursable,138.21,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,138.21,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,82.61,141.53,
EXC-MALIG TRUNK/ARMS/LEGS 0.6 -1.0 CM,67911601,CDM,983,RC,11602,HCPCS,Outpatient,,,179,179,,,,,,Other,Not Separately Reimbursable,163.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,163.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,171.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,171.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,171.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.15,171.36,
Excision-Malignant Lesions,67911602,CDM,983,RC,11603,HCPCS,Outpatient,,,196,196,,,,,,Other,Not Separately Reimbursable,176.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,176.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,185.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,185.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,185.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.68,185.75,
EXC-MALIG TRUNK/ARMS/LEGS 2.1-3.0 CM,67911603,CDM,983,RC,11604,HCPCS,Outpatient,,,237,237,,,,,,Other,Not Separately Reimbursable,196.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,196.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.91,223.82,
EXC-MALIG TRUNK/ARMS/LEGS 3.1-4.0 CM,67911604,CDM,983,RC,11606,HCPCS,Outpatient,,,261,261,,,,,,Other,Not Separately Reimbursable,214.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,214.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,247.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,247.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,247.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,143.3,247.28,
EXCISION OF MALIGNANT LESION>4CM,67911606,CDM,983,RC,11620,HCPCS,Outpatient,,,390,390,,,,,,Other,Not Separately Reimbursable,271.53,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,271.53,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,372.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,372.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,372.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,215.06,372.23,
EXC-MALIG SP/NK/H/F/G <0.5 CM,67911620,CDM,983,RC,11621,HCPCS,Outpatient,,,145,145,,,,,,Other,Not Separately Reimbursable,136.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,136.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,83.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,142.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,83.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,142.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,83.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,83.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,83.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,142.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,83.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,83.07,142.28,
EXC-MALIG SP/NK/H/F/G 0.6-1.0 CM,67911621,CDM,983,RC,11622,HCPCS,Outpatient,,,180,180,,,,,,Other,Not Separately Reimbursable,170.01,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,170.01,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,100.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.61,172.68,
EXC-MALIG SP/NK/H/F/G 1.1-2.0 CM,67911622,CDM,983,RC,11623,HCPCS,Outpatient,,,206,206,,,,,,Other,Not Separately Reimbursable,194.36,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,194.36,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,113.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,194.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,113.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,194.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,113.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,113.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,113.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,194.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,113.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,113.76,194.9,
EXC-MALIG SP/NK/H/F/G 2.1-3.0 CM,67911623,CDM,983,RC,11624,HCPCS,Outpatient,,,257,257,,,,,,Other,Not Separately Reimbursable,221.38,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,221.38,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,140.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,243.09,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,140.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,243.09,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,140.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,140.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,140.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,243.09,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,140.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,140.99,243.09,
EXC-MALIG SP/NK/H/F/G 3.1-4.0 CM,67911624,CDM,983,RC,11626,HCPCS,Outpatient,,,291,291,,,,,,Other,Not Separately Reimbursable,258.45,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,258.45,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,160.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,277.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,160.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,277.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,160.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,160.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,160.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,277.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,160.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,160.6,277.24,
EXCISION OF MALGNANT LESION>4CM,67911626,CDM,983,RC,11640,HCPCS,Outpatient,,,410,410,,,,,,Other,Not Separately Reimbursable,325.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,325.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,198.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,342.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,198.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,342.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,198.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,198.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,198.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,342.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,198.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,198.22,342.94,
EXC-MALIG FACE/EARS/ETC <0.5CM,67911640,CDM,983,RC,11641,HCPCS,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,150.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,150.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,85.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,145.61,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,85.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,145.61,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,85.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,85.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,85.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,145.61,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,85.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,85.38,150.07,
EXC-MALIG FACE/EARS/ETC 0.6-1.0 CM,67911641,CDM,983,RC,11642,HCPCS,Outpatient,,,188,188,,,,,,Other,Not Separately Reimbursable,200.62,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,200.62,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,104.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,179.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,179.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,104.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,104.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,179.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,104.53,200.62,
EXC-MALIG FACE/EARS/ETC 1.1-2.0 CM,67911642,CDM,983,RC,11643,HCPCS,Outpatient,,,221,221,,,,,,Other,Not Separately Reimbursable,222.92,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,222.92,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,122.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,209.74,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,122.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,209.74,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,122.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,122.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,209.74,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,122.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.53,222.92,
EXC-MALIG FACE/EARS/ETC 2.1-3.0 CM,67911643,CDM,983,RC,11644,HCPCS,Outpatient,,,278,278,,,,,,Other,Not Separately Reimbursable,261.65,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,261.65,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,153.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,263.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,153.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,263.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,153.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,153.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,153.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,263.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,153.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,153.22,263.65,
EXC-MALIG FACE/EARS/ETC 3.1-4.0 CM,67911644,CDM,983,RC,11646,HCPCS,Outpatient,,,346,346,,,,,,Other,Not Separately Reimbursable,327.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,327.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,190.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,328.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,190.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,328.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,190.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,190.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,190.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,328.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,190.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,190.6,328.34,
EXCISION OF MALGNANT LESION>4CM,67911646,CDM,983,RC,11730,HCPCS,Outpatient,,,480,480,,,,,,Other,Not Separately Reimbursable,429.17,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,429.17,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,264.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,457.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,264.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,457.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,264.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,264.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,264.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,457.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,264.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,264.44,457.59,
Separation and removal of the entire nail plate or a portion of nail plate,67911730,CDM,983,RC,11732,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,71.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,71.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.22,71.25,
RMV NAIL PLATE ADD-ON,67911732,CDM,983,RC,11770,HCPCS,Outpatient,,,21,21,,,,,,Other,Not Separately Reimbursable,34.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,34.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,11.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,20.37,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,11.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,20.37,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,11.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,11.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,11.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,20.37,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,11.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,11.77,34.25,
PILONIDAL CYST EXCISION SIMPLE,67911770,CDM,983,RC,11771,HCPCS,Outpatient,,,225,225,,,,,,Other,Not Separately Reimbursable,215.77,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,215.77,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,127.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,221.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,221.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,127.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,127.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,221.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,127.61,221.27,
PILONIDAL CYST EXCISION ESTENSIVE,67911771,CDM,983,RC,11772,HCPCS,Outpatient,,,532,532,,,,,,Other,Not Separately Reimbursable,430.28,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,430.28,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,304.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,535.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,304.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,535.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,304.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,304.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,304.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,535.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,304.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,304.95,535.52,
PILONIDAL CYST EXCISION COMPLICATED,67911772,CDM,983,RC,11901,HCPCS,Outpatient,,,698,698,,,,,,Other,Not Separately Reimbursable,506.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,506.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,399.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,685.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,399.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,685.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,399.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,399.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,399.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,685.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,399.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,399.28,685.91,
"TRMT OF LESION, INJECTION, > 7 LESIONS",67911901,CDM,983,RC,11976,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,58.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,58.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,52.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,52.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,52.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.92,58.5,
"REMOVAL,IMPLANTABLE CONTRACEPTIVE CAPSUL",67911976,CDM,983,RC,12001,HCPCS,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,129.53,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,129.53,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,63.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,63.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,63.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,63.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,63.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,63.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,63.23,129.53,
"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",67912001,CDM,983,RC,12002,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,138.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,138.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.32,138.33,
REPAIR OF SUPERFICIAL WOUND 2.6-7.5CM,67912002,CDM,983,RC,12004,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,150,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,150,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.15,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.15,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.15,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.11,150,
REPAIR SUPERFICIAL WOUND BODY 7.6-12.5CM,67912004,CDM,983,RC,12005,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,173.87,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,173.87,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.61,173.87,
REPAIR SUPERFICIAL WOUND BODY 12.6-20.0c,67912005,CDM,983,RC,12006,HCPCS,Outpatient,,,116,116,,,,,,Other,Not Separately Reimbursable,215.91,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,215.91,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.84,215.91,
REPAIR SUPERFICIAL WOUND BODY 20.1-30.0c,67912006,CDM,983,RC,12007,HCPCS,Outpatient,,,142,142,,,,,,Other,Not Separately Reimbursable,283.06,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,283.06,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.61,283.06,
REPAIR SUPERFICIAL WOUND BODY >30.0cm,67912007,CDM,983,RC,12011,HCPCS,Outpatient,,,179,179,,,,,,Other,Not Separately Reimbursable,315.14,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,315.14,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,99.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,175.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,99.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,175.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,99.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,99.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,99.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,175.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,99.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,99.22,315.14,
"Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes",67912011,CDM,983,RC,12015,HCPCS,Outpatient,,,67,67,,,,,,Other,Not Separately Reimbursable,144.69,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,144.69,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,66.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,66.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,66.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,37.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,37.61,144.69,
REPAIR SUPERFICIAL WOUND/FACE 7.6-12.5CM,67912012,CDM,983,RC,12013,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,236.68,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,236.68,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,81.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,81.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,81.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.38,236.68,
REPAIR SUPERFICIAL WOUND/FACE 2.6-5.0CM,67912013,CDM,983,RC,12014,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,161.51,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,161.51,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,39.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,39.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,39.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,39.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,39.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,39.69,161.51,
REPAIR SUPERFICIAL WOUND/FACE 5.17.5CM,67912014,CDM,983,RC,12015,HCPCS,Outpatient,,,91,91,,,,,,Other,Not Separately Reimbursable,190.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,190.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,90.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,90.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,90.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51,190.18,
REPAIR SUPERFICIAL WOUND/FACE 7.6-12.5CM,67912015,CDM,983,RC,12017,HCPCS,Outpatient,,,114,114,,,,,,Other,Not Separately Reimbursable,236.68,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,236.68,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.38,236.68,
REPAIR SUPERFICIAL WOUND/FACE 20.1-30.0C,67912016,CDM,983,RC,12017,HCPCS,Outpatient,,,156,156,,,,,,Other,Not Separately Reimbursable,373.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,373.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,179.4,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,179.4,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,179.4,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.23,373.64,
REPAIR SUPERFICIAL WOUND/FACE 20.1-30.0C,67912017,CDM,983,RC,12017,HCPCS,Outpatient,,,188,188,,,,,,Other,Not Separately Reimbursable,373.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,373.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.98,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.98,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.98,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.23,373.64,
REPAIR SUPERFICIAL WOUND/FACE >30.0CM,67912018,CDM,983,RC,12020,HCPCS,Outpatient,,,213,213,,,,,,Other,Not Separately Reimbursable,373.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,373.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.98,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.98,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.98,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.23,373.64,
TX SUPERFICAL WOUND DEHISCENCE SIMPLE,67912020,CDM,983,RC,12021,HCPCS,Outpatient,,,226,226,,,,,,Other,Not Separately Reimbursable,192.6,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,192.6,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,220.67,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,220.67,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,220.67,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,192.6,220.67,
TX SUPERFICAL WOUND DEHISCENCE;W/PACKIN,67912021,CDM,983,RC,12031,HCPCS,Outpatient,,,82,82,,,,,,Other,Not Separately Reimbursable,141.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,141.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.3,141.1,
INTMD WD REPAIR S/TR/EXT/2.5CM OR LESS,67912031,CDM,983,RC,12032,HCPCS,Outpatient,,,184,184,,,,,,Other,Not Separately Reimbursable,169.88,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,169.88,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,101.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,174.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,101.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,174.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,101.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,101.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,101.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,174.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,101.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,101.99,174.86,
INTMD WD REPAIR S/TR/EXT 2.6-7.5 CM,67912032,CDM,983,RC,12034,HCPCS,Outpatient,,,234,234,,,,,,Other,Not Separately Reimbursable,187.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,187.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,127.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,218.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,218.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,127.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,127.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,218.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,127.38,218.27,
INTMD WD REPAIR S/TR/EXT 7.6CM-12.5 CM,67912034,CDM,983,RC,,,Outpatient,,,251,251,,,,,,Other,Not Separately Reimbursable,218.6,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,218.6,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,238.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,238.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,238.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,138.44,238.36,
INTMD WD REPAIR S/TR/EXT12.6-20.0CM,67912035,CDM,983,RC,12036,HCPCS,Outpatient,,,291,291,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
INTER WOUND REPAIR/BODY 20.1-30.0CM,67912036,CDM,983,RC,12037,HCPCS,Outpatient,,,341,341,,,,,,Other,Not Separately Reimbursable,336.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,336.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,192.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,333.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,192.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,333.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,192.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,192.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,192.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,333.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,192.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,192.91,336.25,
INTER WOUND REPAIR/BODY >30.0CM,67912037,CDM,983,RC,12041,HCPCS,Outpatient,,,401,401,,,,,,Other,Not Separately Reimbursable,380.01,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,380.01,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,223.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,388.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,223.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,388.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,223.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,223.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,388.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,223.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.37,388.6,
INTER WOUND REPAIR/BODY >2.5,67912041,CDM,983,RC,12042,HCPCS,Outpatient,,,181,181,,,,,,Other,Not Separately Reimbursable,188.13,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,188.13,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,97.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,167.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,97.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,167.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,97.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,97.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,97.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,167.97,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,97.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,97.15,188.13,
REP INTER WOUND NK 2.6 - 7.5 CM,67912042,CDM,983,RC,,,Outpatient,,,241,241,,,,,,Other,Not Separately Reimbursable,205.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,205.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,131.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,225.16,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,131.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,225.16,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,131.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,131.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,131.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,225.16,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,131.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,131.76,225.16,
REP INTER WOUND NK 7.6-12.5CM,67912044,CDM,983,RC,12045,HCPCS,Outpatient,,,260,260,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
REP INTER WOUND NK 12.6-20.0CM,67912045,CDM,983,RC,12046,HCPCS,Outpatient,,,324,324,,,,,,Other,Not Separately Reimbursable,270.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,270.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,183.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,322.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,183.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,322.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,183.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,183.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,183.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,322.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,183.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,183.52,322.13,
INTER REPAIR 20.1-30.3CM,67912046,CDM,983,RC,12051,HCPCS,Outpatient,,,381,381,,,,,,Other,Not Separately Reimbursable,348.65,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,348.65,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,217.35,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,379.19,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,217.35,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,379.19,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,217.35,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,217.35,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,217.35,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,379.19,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,217.35,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,217.35,379.19,
INTMD WD REPAIR F/E/EY/N/L/MM 2.5CM OR >,67912051,CDM,983,RC,12052,HCPCS,Outpatient,,,206,206,,,,,,Other,Not Separately Reimbursable,192.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,192.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,113.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,196.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,113.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,196.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,113.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,113.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,113.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,196.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,113.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,113.99,196.04,
INTMD WD REPAIR FACE2.6-5.0CM,67912052,CDM,983,RC,12053,HCPCS,Outpatient,,,246,246,,,,,,Other,Not Separately Reimbursable,208.13,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,208.13,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,134.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,230.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,230.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,134.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,230.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.07,230.91,
INTMD WD REPAIR /FACE5.1-7.5CM,67912053,CDM,983,RC,12054,HCPCS,Outpatient,,,263,263,,,,,,Other,Not Separately Reimbursable,229.55,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,229.55,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,250.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,250.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,250.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,144.44,250.02,
INTER WD REPAIR /FACE7.6-12.5CM,67912054,CDM,983,RC,12055,HCPCS,Outpatient,,,269,269,,,,,,Other,Not Separately Reimbursable,261.74,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,261.74,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,258.51,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,258.51,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,258.51,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,147.91,261.74,
INTER WD REPAIR /FACE12.6-20.0CM,67912055,CDM,983,RC,12056,HCPCS,Outpatient,,,368,368,,,,,,Other,Not Separately Reimbursable,341.29,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,341.29,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,202.37,354.34,
INTER WD REPAIR /FACE20.1-30.0CM,67912056,CDM,983,RC,12057,HCPCS,Outpatient,,,464,464,,,,,,Other,Not Separately Reimbursable,445.4,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,445.4,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,451.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,451.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,451.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,261.2,451.48,
INTER WD REPAIR /FACE>30.0CM,67912057,CDM,983,RC,13100,HCPCS,Outpatient,,,521,521,,,,,,Other,Not Separately Reimbursable,479.71,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,479.71,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,284.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,493.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,284.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,493.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,284.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,284.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,284.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,493.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,284.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,284.75,493.43,
COMPLEX WD REPAIR/TRUCK1.1-2.5CM,67913100,CDM,983,RC,13100,HCPCS,Outpatient,,,249,249,,,,,,Other,Not Separately Reimbursable,230.77,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,230.77,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.99,232.33,
COMPLEX WD REPAIR/TRUCK2.6-7.5CM,67913101,CDM,983,RC,13102,HCPCS,Outpatient,,,305,305,,,,,,Other,Not Separately Reimbursable,230.77,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,230.77,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,134.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.99,232.33,
COMPLEX WD REPAIR/TRUCK EA ADD<5CM,67913102,CDM,983,RC,13120,HCPCS,Outpatient,,,91,91,,,,,,Other,Not Separately Reimbursable,78.02,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,78.02,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,48.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,84.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,48.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,84.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,48.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,48.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,84.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,48.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.92,84.34,
COMPLEX WD REPAIR/EXTREM1.1-2.5CM,67913120,CDM,983,RC,13121,HCPCS,Outpatient,,,285,285,,,,,,Other,Not Separately Reimbursable,243.55,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,243.55,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,157.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,267.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,157.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,267.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,157.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,157.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,157.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,267.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,157.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,157.37,267.9,
"REPAIR COMPLEX SCALP,ARMS,LEGS;2.6-7.5CM",67913121,CDM,983,RC,13131,HCPCS,Outpatient,,,323,323,,,,,,Other,Not Separately Reimbursable,305.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,305.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,297.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,297.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,297.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,173.06,305.43,
REPAIR WD OR LESION,67913131,CDM,983,RC,13132,HCPCS,Outpatient,,,303,303,,,,,,Other,Not Separately Reimbursable,275.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,275.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,162.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,279.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,162.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,279.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,162.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,162.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,162.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,279.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,162.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,162.91,279.76,
"REPAIR, COMPLEX 2.6 - 7.5CM",67913132,CDM,983,RC,14302,HCPCS,Outpatient,,,381,381,,,,,,Other,Not Separately Reimbursable,408.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,408.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,203.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,350.72,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,203.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,350.72,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,203.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,203.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,203.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,350.72,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,203.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,203.75,408.09,
ADJACENT TISSUE TRSFR EA ADDL 30 SQ CM,67914302,CDM,983,RC,15100,HCPCS,Outpatient,,,271,271,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,152.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,256.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,152.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,256.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,152.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,152.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,152.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,256.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,152.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,152.15,256.3,
"SKIN SPLT GRT,TRNK/ARM/LEG",67915100,CDM,983,RC,15101,HCPCS,Outpatient,,,865,865,,,,,,Other,Not Separately Reimbursable,599.4,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,599.4,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,488.04,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,844.17,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,488.04,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,844.17,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,488.04,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,488.04,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,488.04,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,844.17,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,488.04,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,488.04,844.17,
"SKIN SPLT GRT,TRNK/ARM/LEG ADD",67915101,CDM,983,RC,15101,HCPCS,Outpatient,,,136,136,,,,,,Other,Not Separately Reimbursable,121.27,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,121.27,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,76.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,131.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,76.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,131.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,76.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,76.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,76.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,131.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,76.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,76.38,131.71,
SKIN SPLT GRT FAC/NCK/HF/G,67915120,CDM,983,RC,15121,HCPCS,Outpatient,,,841,841,,,,,,Other,Not Separately Reimbursable,121.27,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,121.27,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,76.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,131.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,76.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,131.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,76.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,76.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,76.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,131.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,76.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,76.38,131.71,
SK SPLT A-GRFT F/N/HG/G ADD ON,67915121,CDM,983,RC,15271,HCPCS,Outpatient,,,162,162,,,,,,Other,Not Separately Reimbursable,184.72,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,184.72,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,92.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,158.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,92.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,158.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,92.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,92.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,92.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,158.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,92.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,92.07,184.72,
APPL OF SKIN SUBS GRFT UP TO 100CM,67915271,CDM,983,RC,15275,HCPCS,Outpatient,,,102,102,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,56.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,98.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,56.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,98.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,56.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,56.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,56.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,98.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,56.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,56.77,98.36,
APPL SKIN SUB GRAFT F/S/EL/M/N/E/O/G/H/F,67915275,CDM,983,RC,15931,HCPCS,Outpatient,,,115,115,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,63.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,63.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,63.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,63.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,63.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,63.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,63.23,108.79,
"EXC, SACRAL PRESSURE ULCER, W/PRIM SUTUR",67915931,CDM,983,RC,16020,HCPCS,Outpatient,,,841,841,,,,,,Other,Not Separately Reimbursable,575.82,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,575.82,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,500.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,845.47,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,500.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,845.47,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,500.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,500.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,500.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,845.47,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,500.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,500.12,845.47,
SKIN BURNSDRESS/DEBRID P-THICK S,67916020,CDM,983,RC,16025,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,65.79,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,65.79,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.49,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.49,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.49,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.92,65.79,
SKIN BURNSDRESS/DEBRID P-THICK M,67916025,CDM,983,RC,16030,HCPCS,Outpatient,,,135,135,,,,,,Other,Not Separately Reimbursable,128.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,128.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,75.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,75.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,75.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,75.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,75.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,75.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,75.09,129.59,
SKIN BURNSDRESS/DEBRID P-THICK L,67916030,CDM,983,RC,17110,HCPCS,Outpatient,,,164,164,,,,,,Other,Not Separately Reimbursable,172.74,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,172.74,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,89.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,156.06,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,89.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,156.06,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,89.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,89.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,89.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,156.06,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,89.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,89.3,172.74,
Destruction of 1-14 common or plantar warts,67917110,CDM,983,RC,17250,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,57.39,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,57.39,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,44.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,76.29,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,44.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,76.29,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,44.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,44.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,44.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,76.29,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,44.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,44.54,76.29,
Chemical destruction of pre-cancerous lesions of the skin,67917250,CDM,983,RC,19000,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,42.01,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,42.01,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.41,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,24.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.41,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,24.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,24.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,24.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.41,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,24.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,24.72,43.41,
ASPRATION OF BREAST CYST,67919000,CDM,983,RC,19001,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,70.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,70.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,50.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,28.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,50.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,28.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,28.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,28.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,50.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,28.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,28.84,70.67,
ASPIRATION OF BREAST CYST ADD-ON,67919001,CDM,983,RC,19020,HCPCS,Outpatient,,,26,26,,,,,,Other,Not Separately Reimbursable,41.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,41.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,14.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,24.12,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,14.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,24.12,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,14.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,14.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,14.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,24.12,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,14.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,14.31,41.07,
I&D BREAST ABSCESS,67919020,CDM,983,RC,19020,HCPCS,Outpatient,,,372,372,,,,,,Other,Not Separately Reimbursable,345.44,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,345.44,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,213.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,371.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,213.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,371.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,213.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,213.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,213.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,371.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,213.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,213.76,371.75,
INJECTION BREAST X-RAY,67919030,CDM,983,RC,19100,HCPCS,Outpatient,,,94,94,,,,,,Other,Not Separately Reimbursable,345.44,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,345.44,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.1,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.1,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.1,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94,345.44,
BREAST BIOPSY NEEDLE,67919100,CDM,983,RC,19101,HCPCS,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,149.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,149.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,47.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,84.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,47.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,84.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,47.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,47.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,47.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,84.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,47.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,47.54,149.07,
BREAST BIOPSY OPEN,67919101,CDM,983,RC,19120,HCPCS,Outpatient,,,271,271,,,,,,Other,Not Separately Reimbursable,418.38,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,418.38,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,153.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,268.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,153.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,268.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,153.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,153.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,153.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,268.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,153.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,153.91,418.38,
REMOVAL OF BREAST LESION,67919120,CDM,983,RC,19300,HCPCS,Outpatient,,,507,507,,,,,,Other,Not Separately Reimbursable,383.71,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,383.71,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,286.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,501.88,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,286.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,501.88,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,286.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,286.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,286.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,501.88,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,286.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,286.83,501.88,
REMOVAL OF BREAST TISSUE,67919300,CDM,983,RC,19301,HCPCS,Outpatient,,,503,503,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,290.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,514.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,290.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,514.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,290.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,290.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,290.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,514.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,290.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,290.83,514.79,
PARTIAL MASTECTOMY,67919301,CDM,983,RC,19302,HCPCS,Outpatient,,,1544,1544,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,472.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,798.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,472.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,798.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,472.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,472.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,472.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,798.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,472.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,472.68,798.02,
PARTIAL MASTECTOMY W/LN REMOVAL,67919302,CDM,983,RC,19307,HCPCS,Outpatient,,,2130,2130,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,649.73,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,1096.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,649.73,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,1096.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,649.73,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,649.73,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,649.73,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,1096.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,649.73,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,649.73,1096.5,
REMOVAL BREAST,67919307,CDM,983,RC,20102,HCPCS,Outpatient,,,2833,2833,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,846.9,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,1425.22,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,846.9,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,1425.22,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,846.9,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,846.9,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,846.9,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,1425.22,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,846.9,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,846.9,1425.22,
"EXPLORE WOUND, ABDOMEN",67920102,CDM,983,RC,20205,HCPCS,Outpatient,,,315,315,,,,,,Other,Not Separately Reimbursable,274.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,274.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,175.36,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,304.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,175.36,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,304.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,175.36,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,175.36,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,175.36,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,304.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,175.36,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,175.36,304.9,
MUSCLE BIOPSY DEEP,67920205,CDM,983,RC,20206,HCPCS,Outpatient,,,194,194,,,,,,Other,Not Separately Reimbursable,213.55,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,213.55,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,104.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,104.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,104.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,104.99,213.55,
BIOPSY MUSCLE PERCUTANEOUS NEEDLE,67920206,CDM,983,RC,20250,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,131.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,131.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,66.21,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,38.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,66.21,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,38.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,38.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,66.21,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,38.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.54,131.57,
"BIOPSY, VERTEBRAL BODY, OPEN;THORACIC",67920250,CDM,983,RC,20250,HCPCS,Outpatient,,,478,478,,,,,,Other,Not Separately Reimbursable,378.72,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,378.72,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,257.55,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,465.95,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,257.55,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,465.95,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,257.55,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,257.55,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,257.55,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,465.95,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,257.55,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,257.55,465.95,
REMOVAL FOREIGN BODY MUSCLE OR TEN,67920520,CDM,983,RC,20525,HCPCS,Outpatient,,,176,176,,,,,,Other,Not Separately Reimbursable,378.72,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,378.72,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,176,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,202.4,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,176,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,202.4,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,176,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,176,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,176,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,202.4,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,176,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,176,378.72,
REM OF FOR BODY MUSC/TEND SHEATH;COMPLIC,67920525,CDM,983,RC,21555,HCPCS,Outpatient,,,300,300,,,,,,Other,Not Separately Reimbursable,346.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,346.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,168.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,291.93,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,168.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,291.93,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,168.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,168.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,168.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,291.93,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,168.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,168.45,346.03,
RMV TUMOR NECK/THORAX SUBCUT <3 CM,67921555,CDM,983,RC,21920,HCPCS,Outpatient,,,370,370,,,,,,Other,Not Separately Reimbursable,311.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,311.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,209.64,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,363.47,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,209.64,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,363.47,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,209.64,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,209.64,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,209.64,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,363.47,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,209.64,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,209.64,363.47,
BIOPSY BACK/FLANK SUPERFICIAL,67921920,CDM,983,RC,21925,HCPCS,Outpatient,,,191,191,,,,,,Other,Not Separately Reimbursable,154.53,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,154.53,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,105.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,180.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,105.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,180.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,105.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,105.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,180.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,105.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.92,180.5,
BIOPSY BACK /FLANK DEEP,67921925,CDM,983,RC,21930,HCPCS,Outpatient,,,431,431,,,,,,Other,Not Separately Reimbursable,494.36,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,494.36,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,249.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,446.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,249.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,446.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,249.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,249.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,249.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,446.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,249.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,249.43,494.36,
RMV TUMOR BACK/FLANK,67921930,CDM,983,RC,21932,HCPCS,Outpatient,,,444,444,,,,,,Other,Not Separately Reimbursable,362.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,362.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,249.67,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,434.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,249.67,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,434.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,249.67,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,249.67,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,249.67,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,434.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,249.67,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,249.67,434.14,
EXCISION TUMOR SOFT TISSUE BACK <5CM,67921932,CDM,983,RC,23075,HCPCS,Outpatient,,,812,812,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,474.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,799.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,474.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,799.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,474.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,474.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,474.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,799.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,474.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,474.45,799.27,
RMV TUMOR SHOULDER SUBCUTANEOUS,67923075,CDM,983,RC,23075,HCPCS,Outpatient,,,398,398,,,,,,Other,Not Separately Reimbursable,256.61,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,256.61,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,225.5,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,389.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,225.5,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,389.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,225.5,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,225.5,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,225.5,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,389.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,225.5,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,225.5,389.65,
"RMV SHOULDER TUMOR ,DEEP",67923076,CDM,983,RC,25111,HCPCS,Outpatient,,,658,658,,,,,,Other,Not Separately Reimbursable,256.61,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,256.61,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,225.5,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,389.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,225.5,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,389.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,225.5,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,225.5,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,225.5,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,389.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,225.5,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,225.5,389.65,
"RMV WRIST TENDON ,PRIMARY",67925111,CDM,983,RC,25112,HCPCS,Outpatient,,,384,384,,,,,,Other,Not Separately Reimbursable,342.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,342.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,383.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,383.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,383.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,230.03,383.69,
"RMV WRIST TENDON ,RECURRENT",67925112,CDM,983,RC,26010,HCPCS,Outpatient,,,465,465,,,,,,Other,Not Separately Reimbursable,419.29,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,419.29,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,277.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,463.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,277.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,463.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,277.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,277.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,277.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,463.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,277.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,277.57,463.27,
FINGER ABCESS SIMPLE,67926010,CDM,983,RC,26011,HCPCS,Outpatient,,,163,163,,,,,,Other,Not Separately Reimbursable,201.34,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,201.34,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,95.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,164.77,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,95.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,164.77,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,95.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,95.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,95.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,164.77,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,95.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,95.03,201.34,
FINGER ABCESS COMPLEX,67926011,CDM,983,RC,26115,HCPCS,Outpatient,,,222,222,,,,,,Other,Not Separately Reimbursable,294.08,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,294.08,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,127.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,218.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,218.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,127.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,127.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,218.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,127.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,127.14,294.08,
"REMOVAL HAND LESION,SUBCUT",67926115,CDM,983,RC,26160,HCPCS,Outpatient,,,400,400,,,,,,Other,Not Separately Reimbursable,383.35,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,383.35,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,227.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,392.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,227.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,392.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,227.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,227.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,227.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,392.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,227.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,227.29,392.31,
REMOVE TENDON SHEATH LESION,67926160,CDM,983,RC,26951,HCPCS,Outpatient,,,399,399,,,,,,Other,Not Separately Reimbursable,355.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,355.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,216.39,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,373.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,216.39,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,373.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,216.39,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,216.39,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,216.39,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,373.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,216.39,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,216.39,373.52,
AMPUTATION FINGER/THUMB,67926951,CDM,983,RC,27047,HCPCS,Outpatient,,,1474,1474,,,,,,Other,Not Separately Reimbursable,544.98,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,544.98,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,476.74,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,818.18,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,476.74,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,818.18,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,476.74,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,476.74,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,476.74,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,818.18,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,476.74,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,476.74,818.18,
RMV TUMOR PELVIS/HIP SUPERFICIAL,67927047,CDM,983,RC,27048,HCPCS,Outpatient,,,440,440,,,,,,Other,Not Separately Reimbursable,587.35,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,587.35,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,247.19,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,430.51,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,247.19,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,430.51,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,247.19,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,247.19,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,247.19,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,430.51,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,247.19,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,247.19,587.35,
RMV TUMOR PELVIS/HIP TUMOR DEEP,67927048,CDM,983,RC,27327,HCPCS,Outpatient,,,746,746,,,,,,Other,Not Separately Reimbursable,518.6,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,518.6,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,435.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,733.95,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,435.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,733.95,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,435.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,435.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,435.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,733.95,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,435.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,435.57,733.95,
EXC TUMOR SUBCUTANEOUS,67927327,CDM,983,RC,30000,HCPCS,Outpatient,,,380,380,,,,,,Other,Not Separately Reimbursable,435.36,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,435.36,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,215.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,373.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,215.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,373.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,215.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,215.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,215.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,373.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,215.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,215.01,435.36,
"DRAINAGE ABCESS/HEMATOMA,NASAL INTERNA",67930000,CDM,983,RC,31575,HCPCS,Outpatient,,,139,139,,,,,,Other,Not Separately Reimbursable,129.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,129.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,80.9,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.54,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.9,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.54,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.9,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.9,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,80.9,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.54,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.9,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.9,141.54,
"Flexible, fiberoptic diagnostic laryngoscopy",67931575,CDM,983,RC,36556,HCPCS,Outpatient,,,153,153,,,,,,Other,Not Separately Reimbursable,117.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,117.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,45.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,45.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,45.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,45.24,117.1,
CENTRAL LINE > 5 YEARS,67936556,CDM,983,RC,36558,HCPCS,Outpatient,,,118,118,,,,,,Other,Not Separately Reimbursable,310.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,310.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,99.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,99.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,99.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,57,310.16,
TUNNELED CENT. LINE > 5 YRS,67936558,CDM,983,RC,36569,HCPCS,Outpatient,,,319,319,,,,,,Other,Not Separately Reimbursable,695.23,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,695.23,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,175.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,303.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,175.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,303.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,175.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,175.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,175.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,303.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,175.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,175.14,695.23,
INSERT OF PICC LINE W/O SUBC PORT;5OR>,67936569,CDM,983,RC,36582,HCPCS,Outpatient,,,103,103,,,,,,Other,Not Separately Reimbursable,343.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,343.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,65.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,110.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,65.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,110.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,65.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,65.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,65.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,110.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,65.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,65.76,343.57,
"REPLACE,COMPLETE, TUNNELED CENTR INSERTE",67936582,CDM,983,RC,36589,HCPCS,Outpatient,,,355,355,,,,,,Other,Not Separately Reimbursable,1187.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,1187.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,195.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,338.66,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,195.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,338.66,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,195.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,195.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,195.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,338.66,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,195.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,195.45,1187.67,
REMOVAL TUNNELED CATHETER,67936589,CDM,983,RC,36590,HCPCS,Outpatient,,,166,166,,,,,,Other,Not Separately Reimbursable,176.78,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,176.78,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,92.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,160.09,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,92.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,160.09,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,92.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,92.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,92.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,160.09,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,92.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,92.99,176.78,
PROTACATH REMOVAL,67936590,CDM,983,RC,38500,HCPCS,Outpatient,,,236,236,,,,,,Other,Not Separately Reimbursable,375.66,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,375.66,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,129.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,129.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,129.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,129.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,129.43,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.43,375.66,
"BIOPSY OR EXC OF LYMPH NODES;OPEN,SUPERF",67938500,CDM,983,RC,40800,HCPCS,Outpatient,,,313,313,,,,,,Other,Not Separately Reimbursable,208.63,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,208.63,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,175.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,306.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,175.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,306.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,175.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,175.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,175.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,306.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,175.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,175.6,306.82,
DRAINAGE ABSCESS IN MOUTH-SIMPLE,67940800,CDM,983,RC,43255,HCPCS,Outpatient,,,157,157,,,,,,Other,Not Separately Reimbursable,107.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,107.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,134.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,80.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.76,134.94,
"EGD W/CONTROL OF BLEEDING, ANY METHOD",67943255,CDM,983,RC,43762,HCPCS,Outpatient,,,248,248,,,,,,Other,Not Separately Reimbursable,269.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,269.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,135.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,231.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,135.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,231.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,135.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,135.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,135.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,231.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,135.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,135.44,269.33,
REPLACEMENT OF GASTRO TUBE W/O IMAGING,67943762,CDM,983,RC,44205,HCPCS,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,44.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,44.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,44.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.15,44.07,
"LAPAR,COLECTOMY,PARTIAL W/REM TERM ILIEM",67944205,CDM,983,RC,45300,HCPCS,Outpatient,,,3189,3189,,,,,,Other,Not Separately Reimbursable,1243.37,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,1243.37,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,949.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,1598.81,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,949.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,1598.81,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,949.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,949.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,949.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,1598.81,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,949.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,949.13,1598.81,
PROCTOSIGMOIDOSCOPY,67945300,CDM,983,RC,45305,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,55.78,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,55.78,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,32.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,56.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,32.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,56.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,32.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,32.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,32.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,56.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,32.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,32.31,56.64,
SIGMOIDOSCOPY-RIGID DIAG,67945305,CDM,983,RC,45320,HCPCS,Outpatient,,,90,90,,,,,,Other,Not Separately Reimbursable,69.91,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,69.91,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,85.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,85.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,49.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,85.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.38,85.59,
PROCTOSIGMOIDOSCOPY W/ABLATION,67945320,CDM,983,RC,45330,HCPCS,Outpatient,,,130,130,,,,,,Other,Not Separately Reimbursable,133.71,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,133.71,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,70.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,126.21,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,126.21,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,70.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,126.21,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.3,133.71,
SIGMOIDOSCOPY FLEX DAIG,67945330,CDM,983,RC,45331,HCPCS,Outpatient,,,69,69,,,,,,Other,Not Separately Reimbursable,95.08,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,95.08,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,37.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,65.16,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,37.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,65.16,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,37.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,37.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,37.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,65.16,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,37.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,37.77,95.08,
SIGMOIDOSCOPY FLEX BIOPSY,67945331,CDM,983,RC,45331,HCPCS,Outpatient,,,169,169,,,,,,Other,Not Separately Reimbursable,115.93,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,115.93,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,48.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,83.11,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,48.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,83.11,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,48.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,48.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,83.11,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,48.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.23,115.93,
SIGMOIDOSCOPY W/TUMR REMOVE,67945338,CDM,983,RC,45915,HCPCS,Outpatient,,,286,286,,,,,,Other,Not Separately Reimbursable,115.93,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,115.93,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,48.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,83.11,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,48.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,83.11,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,48.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,48.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,83.11,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,48.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.23,115.93,
REM OF FECAL IMPAC/FOREIGN BODY W/ANESTH,67945915,CDM,983,RC,46040,HCPCS,Outpatient,,,275,275,,,,,,Other,Not Separately Reimbursable,209.69,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,209.69,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,158.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,270.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,158.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,270.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,158.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,158.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,158.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,270.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,158.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,158.07,270.3,
I&D ISCHIORECTAL/PERIRECTAL ABSCESS,67946040,CDM,983,RC,46045,HCPCS,Outpatient,,,513,513,,,,,,Other,Not Separately Reimbursable,368.59,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,368.59,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,291.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,503.21,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,291.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,503.21,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,291.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,291.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,291.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,503.21,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,291.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,291.08,503.21,
I&D INTRAMURAL/INTRAMUS/SUBMUC ABSC W/AN,67946045,CDM,983,RC,46050,HCPCS,Outpatient,,,528,528,,,,,,Other,Not Separately Reimbursable,275.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,275.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,315.17,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,519.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,315.17,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,519.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,315.17,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,315.17,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,315.17,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,519.03,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,315.17,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,275.18,519.03,
"I&D, PERIANAL ABSCESS, SUPERFICIAL",67946050,CDM,983,RC,46060,HCPCS,Outpatient,,,118,118,,,,,,Other,Not Separately Reimbursable,147.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,147.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,68.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,119.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,119.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,68.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,119.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.22,147.67,
INCISION OF RECTAL ABCESS,67946060,CDM,983,RC,46083,HCPCS,Outpatient,,,579,579,,,,,,Other,Not Separately Reimbursable,393.82,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,393.82,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,346.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,574.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,346.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,574.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,346.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,346.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,346.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,574.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,346.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,346.29,574.48,
INCISION THROMBOSED HEMORRHOID EXT,67946083,CDM,983,RC,46221,HCPCS,Outpatient,,,129,129,,,,,,Other,Not Separately Reimbursable,184.62,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,184.62,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,74.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,74.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,74.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,74.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,74.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,74.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,74.92,184.62,
HEMORRHOID BANDING,67946221,CDM,983,RC,46230,HCPCS,Outpatient,,,229,229,,,,,,Other,Not Separately Reimbursable,148.06,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,148.06,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,132.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.85,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,132.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.85,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,132.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,132.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,132.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.85,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,132.13,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,132.13,223.85,
HEMORRHOID TAG REMOVAL,67946230,CDM,983,RC,46250,HCPCS,Outpatient,,,211,211,,,,,,Other,Not Separately Reimbursable,224.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,224.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,117.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,204.63,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,117.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,204.63,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,117.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,117.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,117.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,204.63,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,117.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,117.91,224.52,
"HEMORRHOIDECTOMY, EXTERNAL, COMPLETE",67946250,CDM,983,RC,46255,HCPCS,Outpatient,,,738,738,,,,,,Other,Not Separately Reimbursable,362.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,362.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,219.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,376.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,219.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,376.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,219.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,219.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,219.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,376.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,219.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,219.99,376.6,
HEMORRHOIDECTOMY-SIMPLE,67946255,CDM,983,RC,46320,HCPCS,Outpatient,,,829,829,,,,,,Other,Not Separately Reimbursable,433.91,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,433.91,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,245.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,420.58,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,245.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,420.58,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,245.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,245.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,245.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,420.58,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,245.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,245.98,433.91,
"EXCISION OF THROMBOSED HEMORRHOID, EXTER",67946320,CDM,983,RC,46505,HCPCS,Outpatient,,,135,135,,,,,,Other,Not Separately Reimbursable,172.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,172.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,133.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,133.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,133.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,77.08,172.43,
CHEMODENERVATION OF INTERNAL ANAL SPHINC,67946505,CDM,983,RC,46600,HCPCS,Outpatient,,,289,289,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,167.56,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,294.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,167.56,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,294.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,167.56,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,167.56,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,167.56,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,294.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,167.56,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,167.56,294.23,
ANOSCOPY DIAGNOSTIC,67946600,CDM,983,RC,46606,HCPCS,Outpatient,,,50,50,,,,,,Other,Not Separately Reimbursable,44.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,44.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,27.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,27.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27.52,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,27.52,48.33,
ANOSCOPY W/BX,67946606,CDM,983,RC,49083,HCPCS,Outpatient,,,178,178,,,,,,Other,Not Separately Reimbursable,61.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,61.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.47,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.47,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.47,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.23,88.47,
ABDOMINAL PARACENTESIS W/IMAGING GUIDANC,67949083,CDM,983,RC,55060,HCPCS,Outpatient,,,131,131,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,71.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,71.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.53,122.75,
REPAIR TUNICA VAGAINALIS HYDROCELE,67955060,CDM,983,RC,55100,HCPCS,Outpatient,,,461,461,,,,,,Other,Not Separately Reimbursable,357.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,357.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,267.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,442.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,267.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,442.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,267.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,267.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,267.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,442.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,267.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,267.82,442.52,
DRAINAGE OF SCROTAL WALL ABCESS,67955100,CDM,983,RC,56405,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,338.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,338.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,113.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,195.12,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,113.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,195.12,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,113.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,113.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,113.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,195.12,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,113.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,113.53,338.33,
I&D OF PERINEAL ABSCESS,67956405,CDM,983,RC,56420,HCPCS,Outpatient,,,128,128,,,,,,Other,Not Separately Reimbursable,130.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,130.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,82.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,147.2,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,147.2,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,82.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,82.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,147.2,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,82.1,147.2,
DRAINAGE OF GLAND ABSCESS,67956420,CDM,983,RC,69210,HCPCS,Outpatient,,,108,108,,,,,,Other,Not Separately Reimbursable,127.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,127.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,71.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.2,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.2,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,71.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.2,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.09,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.09,127.5,
Removal of ear wax from one or both ears,67969210,CDM,983,RC,25111,HCPCS,Outpatient,,,39,39,,,,,,Other,Not Separately Reimbursable,61.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,61.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,22.38,61.33,
"RMV WRIST TENDON ,PRIMARY",67990001,CDM,983,RC,93010,HCPCS,Outpatient,,,398,398,,,,,,Other,Not Separately Reimbursable,342.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,342.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,383.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,383.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,383.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,230.03,383.69,
EKG INTERPRETATION & REPORT,67993010,CDM,985,RC,97597,HCPCS,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,10.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,10.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,9.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,9.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,9.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,5.76,10.46,
"Debridement (for example, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps)",67997597,CDM,983,RC,97605,HCPCS,Outpatient,,,28,28,,,,,,Other,Not Separately Reimbursable,48.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,48.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,32.2,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,18.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,32.2,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,18.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,18.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,18.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,32.2,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,18.12,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,18.12,48.03,
NEG PRESS WOUND THERAPY < OR = 50 SQ CM,67997605,CDM,983,RC,97606,HCPCS,Outpatient,,,31,31,,,,,,Other,Not Separately Reimbursable,33.83,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,33.83,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.22,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.22,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.22,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,28.22,33.83,
NEG PRESS WOUND THERAPY > 50 SQ CM,67997606,CDM,983,RC,99201,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,56.48,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,56.48,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,30.53,56.48,
OFFICE VISIT 10 MIN NEW,67999201,CDM,983,RC,99202,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,34.44,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,34.44,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.44,34.44,
"New patient office or other outpatient visit, typically 10 minutes",67999202,CDM,983,RC,99203,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,60.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,60.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33,60.3,
"New patient office or other outpatient visit, typically 30 min",67999203,CDM,983,RC,99204,HCPCS,Outpatient,,,91,91,,,,,,Other,Not Separately Reimbursable,89.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,89.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.23,96.86,
"New patient office of other outpatient visit, typically 45 min",67999204,CDM,983,RC,99205,HCPCS,Outpatient,,,153,153,,,,,,Other,Not Separately Reimbursable,129.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,129.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,154.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,154.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,154.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.62,154.99,
"New patient office of other outpatient visit, typically 60 min",67999205,CDM,983,RC,99211,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,163.15,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,163.15,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,210.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,210.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,210.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.42,210.34,
Outpatient visit of established patient not requiring a physician,67999211,CDM,983,RC,99212,HCPCS,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,19.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,19.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,10.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,10.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,10.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,5.51,19.16,
Outpatient visit of established patient requiring a physician,67999212,CDM,983,RC,99213,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,34.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,34.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,17.48,34.81,
"Established patient office or other outpatient visit, typically 15 minutes",67999213,CDM,983,RC,99214,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,48.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,48.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.62,69,
"Established patient office or other outpatient visit, typically 25 minutes",67999214,CDM,983,RC,99215,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,76.35,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,76.35,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.15,105.8,
"Established patient office or other outpatient, visit typically 40 minutes",67999215,CDM,983,RC,99217,HCPCS,Outpatient,,,131,131,,,,,,Other,Not Separately Reimbursable,113.7,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,113.7,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,150.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,150.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,150.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,67.08,150.65,
OBSERVATION CARE DISCHARGE,67999217,CDM,983,RC,99218,HCPCS,Outpatient,,,165,165,,,,,,Other,Not Separately Reimbursable,67.62,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,67.62,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,49.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,49.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,49.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,49.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.68,67.62,
"OBSERVATION CARE, INITIAL LOW",67999218,CDM,983,RC,99219,HCPCS,Outpatient,,,227,227,,,,,,Other,Not Separately Reimbursable,69.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,69.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,67.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,67.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,67.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,67.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,67.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,67.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,67.92,69.07,
"OBSERVATION CARE, INITIAL MODERATE",67999219,CDM,983,RC,99220,HCPCS,Outpatient,,,308,308,,,,,,Other,Not Separately Reimbursable,114.23,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,114.23,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,91.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,91.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,91.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,91.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,91.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,91.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,91.91,114.23,
"OBSERVATION CARE, INITIAL HIGH",67999220,CDM,983,RC,99221,HCPCS,Outpatient,,,421,421,,,,,,Other,Not Separately Reimbursable,156.84,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,156.84,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,124.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,124.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,124.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,124.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,124.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.07,156.84,
"HOSPITAL CARE, INITIAL LOW",67999221,CDM,983,RC,99222,HCPCS,Outpatient,,,231,231,,,,,,Other,Not Separately Reimbursable,69.79,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,69.79,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,69.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,97.51,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,69.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,97.51,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,69.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,69.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,97.51,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,69.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69.79,97.51,
"HOSPITAL CARE, INITIAL MODERATE",67999222,CDM,983,RC,99223,HCPCS,Outpatient,,,310,310,,,,,,Other,Not Separately Reimbursable,114.59,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,114.59,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,93.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,151.49,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,93.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,151.49,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,93.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,93.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,93.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,151.49,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,93.83,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,93.83,151.49,
"HOSPITAL CARE, INITIAL HIGH",67999223,CDM,983,RC,99231,HCPCS,Outpatient,,,459,459,,,,,,Other,Not Separately Reimbursable,156.71,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,156.71,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,137.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,201.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,137.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,201.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,137.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,137.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,137.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,201.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,137.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,137.51,201.27,
"HOSPITAL CARE, SUBSEQUENT, LOW",67999231,CDM,983,RC,99232,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,35.01,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,35.01,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,58.18,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,58.18,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,26.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,26.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,58.18,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,26.68,58.18,
"HOSPITAL CARE, SUBSEQUENT, MODERATE",67999232,CDM,983,RC,99233,HCPCS,Outpatient,,,165,165,,,,,,Other,Not Separately Reimbursable,55.88,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,55.88,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,91.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,91.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,49.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,91.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.44,91.82,
"HOSPITAL CARE, SUBSEQUENT, HIGH",67999233,CDM,983,RC,99234,HCPCS,Outpatient,,,236,236,,,,,,Other,Not Separately Reimbursable,79.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,79.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,71.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,138.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,138.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,71.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,138.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.03,138.14,
"OBSERV/HOSP SAME DAY, LOW",67999234,CDM,983,RC,99235,HCPCS,Outpatient,,,302,302,,,,,,Other,Not Separately Reimbursable,103.92,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,103.92,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,90.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,115.22,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,90.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,115.22,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,90.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,90.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,90.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,115.22,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,90.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,90.47,115.22,
"OBSERV/HOSP SAME DAY, MODERATE",67999235,CDM,983,RC,99236,HCPCS,Outpatient,,,383,383,,,,,,Other,Not Separately Reimbursable,148.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,148.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,114.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,184.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,184.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,114.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,184.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.71,184.69,
"OBSERV/HOSP SAME DAY, HIGH",67999236,CDM,983,RC,99238,HCPCS,Outpatient,,,494,494,,,,,,Other,Not Separately Reimbursable,190.24,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,190.24,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,146.87,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,242.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,146.87,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,242.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,146.87,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,146.87,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,146.87,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,242.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,146.87,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,146.87,242.04,
HOSPITAL DISCHARGE DAY <30 MIN,67999238,CDM,983,RC,99239,HCPCS,Outpatient,,,165,165,,,,,,Other,Not Separately Reimbursable,67.12,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,67.12,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,93.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,93.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,49.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,93.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.92,93.24,
HOSPITAL DISCHARGE DAY >30 MIN,67999239,CDM,983,RC,99201,HCPCS,Outpatient,,,243,243,,,,,,Other,Not Separately Reimbursable,89.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,89.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,72.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,132.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,72.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,132.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,72.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,72.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,72.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,132.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,72.95,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,72.95,132.6,
OFFICE VISIT 10 MIN NEW,79899201,CDM,983,RC,99202,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 20 MIN NEW,79899202,CDM,983,RC,99203,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 30 MIN NEW,79899203,CDM,983,RC,99204,HCPCS,Outpatient,,,91,91,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 45 MIN NEW,79899204,CDM,983,RC,99205,HCPCS,Outpatient,,,153,153,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 60 MIN NEW,79899205,CDM,983,RC,99211,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 5 MIN EST,79899211,CDM,983,RC,99212,HCPCS,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 10 MIN EST,79899212,CDM,983,RC,99213,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 15 MIN EST,79899213,CDM,983,RC,99214,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 25 MIN EST,79899214,CDM,983,RC,99215,HCPCS,Outpatient,,,155,155,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 40 MIN EST,79899215,CDM,983,RC,G0101,HCPCS,Outpatient,,,131,131,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
PELVIC AND BREAST SCREENING EXAM,79900101,CDM,983,RC,G0179,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,37.93,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,37.93,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,32.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,18.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,32.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,18.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,18.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,18.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,32.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,18.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,18.66,37.93,
PHY RECERT FOR MCR COVERED HH SVCS,79900179,CDM,983,RC,G0180,HCPCS,Outpatient,,,93,93,,,,,,Other,Not Separately Reimbursable,59.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,59.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,59.25,
PHY CERTIFICATION FOR MCR COVD HH SVCS,79900180,CDM,983,RC,G0402,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,70.72,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,70.72,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.13,70.72,
INITIAL PREVENTIVE PHYSICAL EXAM (IPPE),79900402,CDM,983,RC,G0438,HCPCS,Outpatient,,,287,287,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.79,151.79,
"ANNUAL WELLNESS VISIT,PPS INITIAL VISIT",79900438,CDM,983,RC,G0439,HCPCS,Outpatient,,,385,385,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,189.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,189.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,189.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,189.52,189.52,
"ANNUAL WELLNESS VISIT,PPS SUB VISIT",79900439,CDM,983,RC,G0511,HCPCS,Outpatient,,,261,261,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147.55,147.55,
"CHRONIC CARE MGMT SVC, 20 MIN",79900511,CDM,983,RC,G2012,HCPCS,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.7,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.7,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.7,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.7,43.7,
VIRTUAL CK IN; BRIEF 5-10 MIN,79902012,CDM,983,RC,10060,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.54,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.54,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.54,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.54,14.54,
Incision and drainage of abscess; simple or single and complex or multiple,79910060,CDM,983,RC,10061,HCPCS,Outpatient,,,116,116,,,,,,Other,Not Separately Reimbursable,87.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,87.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.7,120.26,
I&D ABCESS COMPLICATED OR MULTIPLE,79910061,CDM,983,RC,10120,HCPCS,Outpatient,,,213,213,,,,,,Other,Not Separately Reimbursable,158.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,158.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.29,212.07,
I&D REMOVE FB SIMPLE,79910120,CDM,983,RC,10121,HCPCS,Outpatient,,,123,123,,,,,,Other,Not Separately Reimbursable,102.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,102.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,121.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,121.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,121.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.15,121.26,
I&D REMOVE FB COMPLEX,79910121,CDM,983,RC,10160,HCPCS,Outpatient,,,222,222,,,,,,Other,Not Separately Reimbursable,196.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,196.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,214.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,214.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,214.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.84,214.35,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",79910160,CDM,983,RC,11200,HCPCS,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,94.05,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,94.05,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.38,111.8,
"Removal of skin tags, multiple fibrocutaneous tags, any area",79911200,CDM,983,RC,11400,HCPCS,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,64.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,64.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,50.27,87.42,
EXC-BENIGN TRUNK/ARM/LEGS <0.5 CM,79911400,CDM,983,RC,11401,HCPCS,Outpatient,,,96,96,,,,,,Other,Not Separately Reimbursable,107.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,107.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.77,107.57,
Under Excision-Benign Lesions Procedures on the Skin 0.6-1 CM,79911401,CDM,983,RC,11402,HCPCS,Outpatient,,,124,124,,,,,,Other,Not Separately Reimbursable,126.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,126.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.84,126.52,
EXC-BENIGN TRUNK/ARM/LEGS 1.1-2.0 CM,79911402,CDM,983,RC,11403,HCPCS,Outpatient,,,137,137,,,,,,Other,Not Separately Reimbursable,143.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,143.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,133.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,133.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,133.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,78.28,143.18,
EXC-BENIGN TRUNK/ARM/LEGS 2.1-3.0 CM,79911403,CDM,983,RC,11404,HCPCS,Outpatient,,,178,178,,,,,,Other,Not Separately Reimbursable,166.14,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,166.14,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.38,172.68,
EXC-BENIGN TRUNK/ARM/LEGS 3.1-4.0,79911404,CDM,983,RC,11600,HCPCS,Outpatient,,,196,196,,,,,,Other,Not Separately Reimbursable,183.74,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,183.74,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,191.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,191.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,191.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111,191.76,
EXC-BENIGN TRUNK/ARM/LEGS <0.5CM,79911600,CDM,983,RC,11601,HCPCS,Outpatient,,,144,144,,,,,,Other,Not Separately Reimbursable,138.21,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,138.21,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,82.61,141.53,
EXC-BENIGN TRUNK/ARM/LEGS 0.6-1.0CM,79911601,CDM,983,RC,11602,HCPCS,Outpatient,,,179,179,,,,,,Other,Not Separately Reimbursable,163.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,163.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,171.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,171.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,171.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.15,171.36,
Excision-Malignant Lesions,79911602,CDM,983,RC,11603,HCPCS,Outpatient,,,196,196,,,,,,Other,Not Separately Reimbursable,176.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,176.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,185.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,185.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,185.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.68,185.75,
EXC-BENIGN TRUNK/ARM/LEGS 2.1-3.0CM,79911603,CDM,983,RC,11604,HCPCS,Outpatient,,,237,237,,,,,,Other,Not Separately Reimbursable,196.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,196.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.91,223.82,
EXC-BENIGN TRUNK/ARM/LEGS3.1-4.0CM,79911604,CDM,983,RC,11730,HCPCS,Outpatient,,,261,261,,,,,,Other,Not Separately Reimbursable,214.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,214.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,247.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,247.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,247.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,143.3,247.28,
Separation and removal of the entire nail plate or a portion of nail plate,79911730,CDM,983,RC,11740,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,71.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,71.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.22,71.25,
EVACUATION OF SUBUNGAL HEMATOMA,79911740,CDM,983,RC,11900,HCPCS,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,36.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,36.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,21.22,36.67,
Injections to remove up to 7 lesions on the skin,79911900,CDM,983,RC,11901,HCPCS,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,42.85,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,42.85,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.01,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.01,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,19.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,19.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.01,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,19.84,42.85,
ADDED SKIN LESIONS INJECTION,79911901,CDM,983,RC,12001,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,58.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,58.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,52.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,52.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,52.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.92,58.5,
"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",79912001,CDM,983,RC,12002,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,138.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,138.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.32,138.33,
REPAIR SUPERFICAL WOUND 2.6-7.5CM,79912002,CDM,983,RC,12004,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,150,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,150,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.15,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.15,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.15,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.11,150,
REPAIR SUPERFICAL WOUND 7.6-12.5CM,79912004,CDM,983,RC,12005,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,173.87,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,173.87,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.61,173.87,
REPAIR SUPERFICAL WOUND 12.6-20CM,79912005,CDM,983,RC,12006,HCPCS,Outpatient,,,116,116,,,,,,Other,Not Separately Reimbursable,215.91,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,215.91,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.84,215.91,
REPAIR SUPERFICAL WOUND 20.1-30CM,79912006,CDM,983,RC,12021,HCPCS,Outpatient,,,142,142,,,,,,Other,Not Separately Reimbursable,283.06,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,283.06,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.61,283.06,
TRMT OF SUPERFICIAL WOUND W/PACKING,79912021,CDM,983,RC,17110,HCPCS,Outpatient,,,82,82,,,,,,Other,Not Separately Reimbursable,141.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,141.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.3,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,94.3,141.1,
Destruction of 1-14 common or plantar warts,79917110,CDM,983,RC,17111,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,57.39,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,57.39,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,44.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,76.29,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,44.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,76.29,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,44.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,44.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,44.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,76.29,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,44.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,44.54,76.29,
Destruction of >15 common or plantar warts,79917111,CDM,983,RC,20526,HCPCS,Outpatient,,,114,114,,,,,,Other,Not Separately Reimbursable,73.62,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,73.62,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,54.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,54.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,54.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,54.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,54.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.8,94,
"INJECTION, THERAPEUTIC, CARPAL TUNNEL",79920526,CDM,983,RC,20550,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,38.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,38.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,38.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,38.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.94,68.05,
Injection of medication into a tendon or ligament,79920550,CDM,983,RC,20551,HCPCS,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,91.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,91.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,26.54,91.94,
Injection of medication into the tendon/ligament origin,79920551,CDM,983,RC,20552,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,26.54,63.31,
INJ TRIGGER POINT 1/2 MUSCL,79920552,CDM,983,RC,20553,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.61,63.31,
Injection of medication into an area that triggers pain,79920553,CDM,983,RC,20600,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,29.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.07,63.31,
Draining or injecting medication into a small joint/bursa without ultrasound,79920600,CDM,983,RC,20604,HCPCS,Outpatient,,,43,43,,,,,,Other,Not Separately Reimbursable,68.9,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,68.9,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,41.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,24.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,41.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,24.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,24.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,24.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,41.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,24.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,24.23,68.9,
ARTHROCESPIRATION/INJ;SM JNT/BUR W/US,79920604,CDM,983,RC,20605,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.89,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.89,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,31.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,31.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.89,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,31.15,53.89,
Draining or injecting medication into a large joint/bursa without ultrasound,79920605,CDM,983,RC,20606,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,78.34,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,78.34,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.15,78.34,
ARTHROCESPIRA/INJ; INTER JNT/BUR W/US,79920606,CDM,983,RC,20610,HCPCS,Outpatient,,,65,65,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,61.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,35.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,61.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,35.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,35.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,61.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,35.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.07,61.13,
Draining or injecting medication into a major joint/bursa without ultrasound,79920610,CDM,983,RC,20611,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,94.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,94.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.69,94.3,
ARTHROCESPIRA/INJ; MAJ JNT/BUR W/US,79920611,CDM,983,RC,20612,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.16,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.16,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,40.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.16,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.15,71.16,
Removal of fluid or injection of medication into a ganglion cyst,79920612,CDM,983,RC,26605,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,56.98,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,56.98,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,27.92,56.98,
CLSD TRMT OF METACARPAL FX W/MANIPULATIO,79926605,CDM,983,RC,26641,HCPCS,Outpatient,,,348,348,,,,,,Other,Not Separately Reimbursable,305.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,305.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,202.27,354.55,
TREAT THUMB DISLOCATION,79926641,CDM,983,RC,26725,HCPCS,Outpatient,,,466,466,,,,,,Other,Not Separately Reimbursable,357.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,357.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,238.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,454.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,238.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,454.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,238.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,238.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,238.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,454.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,238.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,238.66,454.94,
CLSD TRMT W/MANIPUL W/WO SKIN/SKEL TRACT,79926725,CDM,983,RC,27328,HCPCS,Outpatient,,,402,402,,,,,,Other,Not Separately Reimbursable,291.54,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,291.54,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,208.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,364.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,208.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,364.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,208.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,208.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,208.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,364.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,208.98,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,208.98,364.71,
"EXC TUMOR,SFT TIS THIGH/KNEE,SUBFASC<5CM",79927328,CDM,983,RC,29065,HCPCS,Outpatient,,,847,847,,,,,,Other,Not Separately Reimbursable,463.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,463.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,444.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,746.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,444.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,746.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,444.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,444.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,444.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,746.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,444.8,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,444.8,746.71,
APPLICATION OF LONG ARM CAST,79929065,CDM,983,RC,29075,HCPCS,Outpatient,,,82,82,,,,,,Other,Not Separately Reimbursable,81.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,81.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,46.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,46.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.18,81.52,
APPLICATION OF FOREARM CAST,79929075,CDM,983,RC,29085,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,74.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,74.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,74.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,74.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,74.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,41.77,74.05,
APPLICATION OF HAND/WRIST CAST,79929085,CDM,983,RC,29105,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,77.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,77.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,45.47,79.04,
APPLICATION OF LONG ARM SPLINT,79929105,CDM,983,RC,29125,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,77.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,77.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.41,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.41,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.41,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,28.71,77.76,
APPLICATION OF FOREARM SPLINT,79929125,CDM,983,RC,29130,HCPCS,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,59.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,59.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,47.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,47.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,47.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,27,59.76,
APPLICATION OF FINGER SPLINT,79929130,CDM,983,RC,29405,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,47.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,47.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,19.82,47.58,
APPL OF SHORT LEG CAST BELOW KNEE TO TOE,79929405,CDM,983,RC,29505,HCPCS,Outpatient,,,72,72,,,,,,Other,Not Separately Reimbursable,78.61,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,78.61,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,39.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,39.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,39.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,39.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,39.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,39.22,78.61,
APPLICATION OF LONG LEG SPLINT,79929505,CDM,983,RC,29515,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,77.99,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,77.99,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,60.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,60.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,60.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.61,77.99,
APPLICATION OF LOWER LEG SPLINT,79929515,CDM,983,RC,69210,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,66.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,66.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,57.74,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,57.74,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,57.74,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33.22,66.57,
Removal of ear wax from one or both ears,79969210,CDM,983,RC,93010,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,61.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,61.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,22.38,61.33,
EKG INTERPRETATION & REPORT,79993010,CDM,985,RC,99183,HCPCS,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,10.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,10.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,9.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,9.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,9.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,5.76,10.46,
HBO THERAPY ATTENDANCE/SUPERVISION,79999183,CDM,983,RC,99201,HCPCS,Outpatient,,,255,255,,,,,,Other,Not Separately Reimbursable,130.19,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,130.19,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,75.34,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,125.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,75.34,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,125.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,75.34,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,75.34,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,75.34,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,125.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,75.34,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,75.34,130.19,
OFFICE VISIT 10 MIN NEW,79999201,CDM,983,RC,99202,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,34.44,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,34.44,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.44,34.44,
"New patient office or other outpatient visit, typically 10 minutes",79999202,CDM,983,RC,99203,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,60.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,60.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33,60.3,
"New patient office or other outpatient visit, typically 30 min",79999203,CDM,983,RC,99204,HCPCS,Outpatient,,,91,91,,,,,,Other,Not Separately Reimbursable,89.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,89.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.23,96.86,
"New patient office of other outpatient visit, typically 45 min",79999204,CDM,983,RC,99205,HCPCS,Outpatient,,,153,153,,,,,,Other,Not Separately Reimbursable,129.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,129.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,154.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,154.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,154.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.62,154.99,
"New patient office of other outpatient visit, typically 60 min",79999205,CDM,983,RC,99211,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,163.15,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,163.15,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,210.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,210.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,210.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.42,210.34,
Outpatient visit of established patient not requiring a physician,79999211,CDM,983,RC,99212,HCPCS,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,19.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,19.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,10.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,10.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,10.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,5.51,19.16,
Outpatient visit of established patient requiring a physician,79999212,CDM,983,RC,99213,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,34.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,34.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,17.48,34.81,
"Established patient office or other outpatient visit, typically 15 minutes",79999213,CDM,983,RC,99214,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,48.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,48.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.62,69,
"Established patient office or other outpatient visit, typically 25 minutes",79999214,CDM,983,RC,99215,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,76.35,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,76.35,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.15,105.8,
"Established patient office or other outpatient, visit typically 40 minutes",79999215,CDM,983,RC,99406,HCPCS,Outpatient,,,131,131,,,,,,Other,Not Separately Reimbursable,113.7,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,113.7,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,150.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,150.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,150.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,67.08,150.65,
"SMOKE/TOB CESS CNSL INTERM, ASYM 3-10MIN",79999406,CDM,983,RC,99407,HCPCS,Outpatient,,,34,34,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,13.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,8.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,13.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,8.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,8.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,8.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,13.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,8.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,8.08,13.78,
"SMOKE/TOB CESS CNSL INTENS, ASYMP >10M",79999407,CDM,983,RC,99441,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,15.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,15.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,15.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,15.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,15.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,15.26,29.07,
"Physician telephone patient service, 5-10 minutes of medical discussion",79999441,CDM,983,RC,99442,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,34.5,
"Physician telephone patient service, 11-20 minutes of medical discussion",79999442,CDM,983,RC,99443,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69,69,
"Physician telephone patient service, 21-30 minutes of medical discussion",79999443,CDM,983,RC,99495,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.35,102.35,
TRANS CARE MGMT 14 DAY DISCH,79999495,CDM,983,RC,99496,HCPCS,Outpatient,,,129,129,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.35,148.35,
TRANS CARE MGMT 7 DAY DISCH,79999496,CDM,983,RC,99497,HCPCS,Outpatient,,,188,188,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216.2,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216.2,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216.2,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216.2,216.2,
"ADVANCED CARE PLANNING, 30 MIN",79999497,CDM,983,RC,99201,HCPCS,Outpatient,,,93,93,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.18,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.18,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.18,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.18,87.18,
OFFICE VISIT 10 MIN NEW,82899201,CDM,983,RC,99202,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 20 MIN NEW,82899202,CDM,983,RC,99203,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 30 MIN NEW,82899203,CDM,983,RC,99204,HCPCS,Outpatient,,,91,91,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 45 MIN NEW,82899204,CDM,983,RC,99205,HCPCS,Outpatient,,,153,153,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 60 MIN NEW,82899205,CDM,983,RC,99211,HCPCS,Outpatient,,,223,223,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 5 MIN EST,82899211,CDM,983,RC,99212,HCPCS,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 10 MIN EST,82899212,CDM,983,RC,99213,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 15 MIN EST,82899213,CDM,983,RC,99214,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 25 MIN EST,82899214,CDM,983,RC,99215,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 40 MIN EST,82899215,CDM,983,RC,10021,HCPCS,Outpatient,,,131,131,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
Fine Needle Aspiration Biopsy without imaging,82910021,CDM,983,RC,10160,HCPCS,Outpatient,,,84,84,,,,,,Other,Not Separately Reimbursable,89.29,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,89.29,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.92,89.29,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",82910160,CDM,983,RC,11056,HCPCS,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,94.05,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,94.05,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.38,111.8,
Paring or cutting of benign hyperkeratotic lesion,82911056,CDM,983,RC,11057,HCPCS,Outpatient,,,27,27,,,,,,Other,Not Separately Reimbursable,30.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,30.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.77,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.77,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.77,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,15,30.16,
EXC BENIGN HYPERTROPHIC SKIN LES > 4,82911057,CDM,983,RC,11300,HCPCS,Outpatient,,,36,36,,,,,,Other,Not Separately Reimbursable,35.49,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,35.49,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33.09,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33.09,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,19.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,19.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33.09,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,19.38,35.49,
"SHAVING OF EPID LES;TRUNK,ARM,LEG <.50CM",82911300,CDM,983,RC,11305,HCPCS,Outpatient,,,43,43,,,,,,Other,Not Separately Reimbursable,54.21,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,54.21,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.86,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,39.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.86,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,39.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.86,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,22.86,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,22.86,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,39.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.86,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,22.86,54.21,
"SHAVING OF EPID LES;SCALP,NECK <.50CM",82911305,CDM,983,RC,11306,HCPCS,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,54.15,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,54.15,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.65,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.92,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.65,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.92,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.65,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.65,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,25.65,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.92,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.65,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.65,54.15,
"SHAVING OF EPID LES;SCALP,NECK .6-1.0CM",82911306,CDM,983,RC,11310,HCPCS,Outpatient,,,63,63,,,,,,Other,Not Separately Reimbursable,75.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,75.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,57.72,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,57.72,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,57.72,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33.22,75.64,
"SHAV EPID/DERM SGL LES,F/E/EL/N/L .5CM<",82911310,CDM,983,RC,11400,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,66.89,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,66.89,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.67,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.67,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.67,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.69,66.89,
EXC TR-EXT B9+MARG 0.5<CM,82911400,CDM,983,RC,11401,HCPCS,Outpatient,,,96,96,,,,,,Other,Not Separately Reimbursable,107.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,107.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.77,107.57,
Under Excision-Benign Lesions Procedures on the Skin 0.6-1 CM,82911401,CDM,983,RC,11403,HCPCS,Outpatient,,,124,124,,,,,,Other,Not Separately Reimbursable,126.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,126.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.84,126.52,
EXC TR-EXT B9+MARG 2.1-3CM,82911403,CDM,983,RC,11406,HCPCS,Outpatient,,,177,177,,,,,,Other,Not Separately Reimbursable,166.14,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,166.14,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.38,172.68,
EXC TR-EXT B9+MARG >4.0CM,82911406,CDM,983,RC,11420,HCPCS,Outpatient,,,300,300,,,,,,Other,Not Separately Reimbursable,220.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,220.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,291.88,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,291.88,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,291.88,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,168.68,291.88,
EXC H-F-NK-SP B9+MARG 0.5<,82911420,CDM,983,RC,11423,HCPCS,Outpatient,,,96,96,,,,,,Other,Not Separately Reimbursable,103.65,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,103.65,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,94.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.61,103.65,
EXC H-F-NK-SP B9+MARG 2.1-3CM,82911423,CDM,983,RC,11424,HCPCS,Outpatient,,,188,188,,,,,,Other,Not Separately Reimbursable,181.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,181.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,180.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,180.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,180.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,105.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.22,181.76,
EXC H-F-NK-SP B9+MARG 3.1-4CM,82911424,CDM,983,RC,11426,HCPCS,Outpatient,,,216,216,,,,,,Other,Not Separately Reimbursable,205.96,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,205.96,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,120.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,207.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,120.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,207.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,120.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,120.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,207.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,120.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.22,207.64,
EXC H-F-NK-SP B9+MARG >4CM,82911426,CDM,983,RC,11440,HCPCS,Outpatient,,,335,335,,,,,,Other,Not Separately Reimbursable,277.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,277.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,184.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,317.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,184.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,317.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,184.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,184.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,184.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,317.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,184.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,184.6,317.02,
EXC-BENIGN FACE/EARS/ETC .5CM OR <,82911440,CDM,983,RC,11442,HCPCS,Outpatient,,,122,122,,,,,,Other,Not Separately Reimbursable,123.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,123.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,70.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,70.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.38,123.67,
EXC BENIGN FACE/EARS/ETC 1.1-2.0 CM,82911442,CDM,983,RC,11444,HCPCS,Outpatient,,,173,173,,,,,,Other,Not Separately Reimbursable,163.65,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,163.65,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,98.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,169.17,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,98.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,169.17,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,98.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,98.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,98.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,169.17,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,98.41,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,98.41,169.17,
EXC FACE-MM B9+MARG 3.1-4CM,82911444,CDM,983,RC,11446,HCPCS,Outpatient,,,273,273,,,,,,Other,Not Separately Reimbursable,256.99,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,256.99,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,152.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,262.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,152.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,262.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,152.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,152.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,152.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,262.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,152.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,152.99,262.38,
EXC FACE-MM B9+MARG >4.0CM,82911446,CDM,983,RC,11600,HCPCS,Outpatient,,,392,392,,,,,,Other,Not Separately Reimbursable,314.96,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,314.96,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,216.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,368.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,216.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,368.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,216.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,216.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,216.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,368.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,216.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,216.68,368.87,
EXC TR-EXT MAL+MARG 0.5<CM,82911600,CDM,983,RC,11601,HCPCS,Outpatient,,,144,144,,,,,,Other,Not Separately Reimbursable,138.21,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,138.21,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,82.61,141.53,
EXC TR-EXT MAL+MARG 0.6-1CM,82911601,CDM,983,RC,11602,HCPCS,Outpatient,,,179,179,,,,,,Other,Not Separately Reimbursable,163.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,163.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,171.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,171.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,171.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.15,171.36,
Excision-Malignant Lesions,82911602,CDM,983,RC,11603,HCPCS,Outpatient,,,197,197,,,,,,Other,Not Separately Reimbursable,176.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,176.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,185.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,185.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,185.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.68,185.75,
EXC TR-EXT MAL+MARG 2.1-3CM,82911603,CDM,983,RC,11604,HCPCS,Outpatient,,,237,237,,,,,,Other,Not Separately Reimbursable,196.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,196.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.91,223.82,
EXC TR-EXT MAL+MARG 3.1-4CM,82911604,CDM,983,RC,11606,HCPCS,Outpatient,,,261,261,,,,,,Other,Not Separately Reimbursable,214.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,214.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,247.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,247.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,247.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,143.3,247.28,
EXC TR-EXT MAL+MARG >4CM,82911606,CDM,983,RC,11620,HCPCS,Outpatient,,,391,391,,,,,,Other,Not Separately Reimbursable,271.53,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,271.53,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,372.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,372.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,372.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,215.06,372.23,
EXC H-F-NK-SP MAL+MARG 0.5<,82911620,CDM,983,RC,11621,HCPCS,Outpatient,,,145,145,,,,,,Other,Not Separately Reimbursable,136.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,136.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,83.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,142.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,83.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,142.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,83.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,83.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,83.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,142.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,83.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,83.07,142.28,
EXC H-F-NK-SP MAL+MARG 0.6-1CM,82911621,CDM,983,RC,11623,HCPCS,Outpatient,,,180,180,,,,,,Other,Not Separately Reimbursable,170.01,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,170.01,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,100.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.61,172.68,
EXC H-F-NK-SP MAL+MARG 2.1-3CM,82911623,CDM,983,RC,11624,HCPCS,Outpatient,,,257,257,,,,,,Other,Not Separately Reimbursable,221.38,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,221.38,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,140.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,243.09,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,140.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,243.09,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,140.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,140.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,140.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,243.09,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,140.99,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,140.99,243.09,
EXC MAL LES SP/NCK/HD/FACE/GENIT 3.1-4CM,82911624,CDM,983,RC,11626,HCPCS,Outpatient,,,291,291,,,,,,Other,Not Separately Reimbursable,258.45,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,258.45,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,160.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,277.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,160.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,277.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,160.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,160.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,160.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,277.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,160.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,160.6,277.24,
EXC H-F-NK-SP MAL+MARG >4CM,82911626,CDM,983,RC,11640,HCPCS,Outpatient,,,358,358,,,,,,Other,Not Separately Reimbursable,325.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,325.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,198.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,342.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,198.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,342.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,198.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,198.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,198.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,342.94,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,198.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,198.22,342.94,
EXC MALIG LES +MARGINS F/E/E/N/L < .5CM,82911640,CDM,983,RC,11641,HCPCS,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,150.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,150.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,85.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,145.61,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,85.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,145.61,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,85.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,85.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,85.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,145.61,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,85.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,85.38,150.07,
EXC MALIG LES +MARGINS F/E/E/N/L .6-1CM,82911641,CDM,983,RC,11644,HCPCS,Outpatient,,,188,188,,,,,,Other,Not Separately Reimbursable,200.62,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,200.62,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,104.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,179.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,179.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,104.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,104.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,179.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,104.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,104.53,200.62,
EXC F/E/E/N/L MAL+MARG 3/1-4CM,82911644,CDM,983,RC,12002,HCPCS,Outpatient,,,346,346,,,,,,Other,Not Separately Reimbursable,327.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,327.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,190.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,328.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,190.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,328.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,190.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,190.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,190.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,328.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,190.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,190.6,328.34,
REPAIR OF SUPERFICIAL WOUND 2.6-7.5CM,82912002,CDM,983,RC,12034,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,150,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,150,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.15,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.15,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.15,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.11,150,
INTMD RPR S/A/T/EXT 7.6-12.5,82912034,CDM,983,RC,12035,HCPCS,Outpatient,,,251,251,,,,,,Other,Not Separately Reimbursable,218.6,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,218.6,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,238.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,238.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,238.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,138.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,138.44,238.36,
INTMD RPR S/A/T/EXT 12.6-20CM,82912035,CDM,983,RC,12036,HCPCS,Outpatient,,,291,291,,,,,,Other,Not Separately Reimbursable,244.63,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,244.63,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,163.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,283.95,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,163.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,283.95,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,163.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,163.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,163.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,283.95,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,163.6,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,163.6,283.95,
INTMD RPR S/A/T/EXT 20.1-30CM,82912036,CDM,983,RC,12037,HCPCS,Outpatient,,,341,341,,,,,,Other,Not Separately Reimbursable,336.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,336.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,192.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,333.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,192.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,333.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,192.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,192.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,192.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,333.59,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,192.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,192.91,336.25,
INTMD RPR S/A/T/EXT >30.0CM,82912037,CDM,983,RC,12053,HCPCS,Outpatient,,,401,401,,,,,,Other,Not Separately Reimbursable,380.01,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,380.01,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,223.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,388.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,223.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,388.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,223.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,223.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,388.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,223.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.37,388.6,
INTMD RPR FACE/MM 5.1-7.5CM,82912053,CDM,983,RC,12054,HCPCS,Outpatient,,,263,263,,,,,,Other,Not Separately Reimbursable,229.55,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,229.55,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,250.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,250.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,250.02,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,144.44,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,144.44,250.02,
INTMD RPR FACE/MM 7.6-12.5CM,82912054,CDM,983,RC,12055,HCPCS,Outpatient,,,269,269,,,,,,Other,Not Separately Reimbursable,261.74,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,261.74,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,258.51,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,258.51,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,258.51,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,147.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,147.91,261.74,
INTMD RPR FACE/MM 12.6-20CM,82912055,CDM,983,RC,12056,HCPCS,Outpatient,,,368,368,,,,,,Other,Not Separately Reimbursable,341.29,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,341.29,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.37,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,202.37,354.34,
INTMD RPR FACE/MM 20.1-30.0CM,82912056,CDM,983,RC,13121,HCPCS,Outpatient,,,464,464,,,,,,Other,Not Separately Reimbursable,445.4,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,445.4,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,451.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,451.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,451.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,261.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,261.2,451.48,
"REPAIR, COMPLEX, SCALP/ARM/LEG 2.6-7.5CM",82913121,CDM,983,RC,20551,HCPCS,Outpatient,,,323,323,,,,,,Other,Not Separately Reimbursable,305.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,305.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,297.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,297.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,297.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,173.06,305.43,
Injection of medication into the tendon/ligament origin,82920551,CDM,983,RC,20605,HCPCS,Outpatient,,,85,85,,,,,,Other,Not Separately Reimbursable,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,26.54,63.31,
Draining or injecting medication into a large joint/bursa without ultrasound,82920605,CDM,983,RC,21014,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,78.34,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,78.34,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.15,78.34,
EXCIS SOFT TISS TUMOR FACE/SCALP 2CM OR>,82921014,CDM,983,RC,30100,HCPCS,Outpatient,,,632,632,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,617.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,371.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,617.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,371.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,371.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,371.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,617.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,371.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,371.01,617.71,
"BIOPSY, INTRANASAL",82930100,CDM,983,RC,30300,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,80.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,80.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,78.58,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,78.58,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,78.58,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,45.47,80.07,
"REMOVAL OF FOREIGN BODY, INTRANASAL",82930300,CDM,983,RC,30903,HCPCS,Outpatient,,,124,124,,,,,,Other,Not Separately Reimbursable,115.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,115.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,77.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,142.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,142.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,77.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,77.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,142.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.31,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,77.31,142.6,
CONTROL NASAL HEM/COMPLEX,82930903,CDM,983,RC,31231,HCPCS,Outpatient,,,95,95,,,,,,Other,Not Separately Reimbursable,138.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,138.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,52.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,93.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,52.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,93.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,52.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,52.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,52.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,93.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,52.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,52.38,138.75,
"Nasal endoscopy, diagnostic, unilateral or bilateral",82931231,CDM,983,RC,31505,HCPCS,Outpatient,,,78,78,,,,,,Other,Not Separately Reimbursable,110.21,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,110.21,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,43.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,76.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,43.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,76.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,43.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,43.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,76.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,43.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.15,110.21,
LARYNOSCOPY THROAT,82931505,CDM,983,RC,31575,HCPCS,Outpatient,,,58,58,,,,,,Other,Not Separately Reimbursable,75.82,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,75.82,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,32.88,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,56.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,32.88,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,56.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,32.88,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,32.88,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,32.88,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,56.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,32.88,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,32.88,75.82,
"Flexible, fiberoptic diagnostic laryngoscopy",82931575,CDM,983,RC,40510,HCPCS,Outpatient,,,80,80,,,,,,Other,Not Separately Reimbursable,117.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,117.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,45.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,45.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,45.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,45.24,117.1,
PARTIAL EXCISION OF LIP,82940510,CDM,983,RC,40808,HCPCS,Outpatient,,,427,427,,,,,,Other,Not Separately Reimbursable,424.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,424.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,237.86,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,407.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,237.86,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,407.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,237.86,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,237.86,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,237.86,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,407.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,237.86,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,237.86,424.22,
"BIOPSY, VESTIBULE OF MOUTH",82940808,CDM,983,RC,40810,HCPCS,Outpatient,,,129,129,,,,,,Other,Not Separately Reimbursable,102.32,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,102.32,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,59.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,101.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,59.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,101.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,59.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,59.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,59.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,101.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,59.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,59.07,102.32,
EXC OF LESION MUCOSA/SUBMOCOSA W/SIM RPR,82940810,CDM,983,RC,40812,HCPCS,Outpatient,,,152,152,,,,,,Other,Not Separately Reimbursable,137.38,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,137.38,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,83.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.93,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,83.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.93,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,83.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,83.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,83.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.93,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,83.25,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,83.25,141.93,
EXC OF LESION MUCOSA/SUBMOCOSA W/O RPR,82940812,CDM,983,RC,42300,HCPCS,Outpatient,,,237,237,,,,,,Other,Not Separately Reimbursable,187.35,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,187.35,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,126.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.19,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,126.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.19,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,126.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,126.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,126.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.19,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,126.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,126.22,212.19,
"DRAINAGE OF ABSCESS; PAROTID, SIMPLE",82942300,CDM,983,RC,42330,HCPCS,Outpatient,,,182,182,,,,,,Other,Not Separately Reimbursable,158.41,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,158.41,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,105.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,182.93,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,105.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,182.93,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,105.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,105.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,182.93,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,105.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.08,182.93,
SIALOLITHOTOMY; PAROTID UNCOMP INTRAORAL,82942330,CDM,983,RC,42800,HCPCS,Outpatient,,,197,197,,,,,,Other,Not Separately Reimbursable,174.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,174.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,111.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,193.32,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,111.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,193.32,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,111.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,111.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,193.32,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,111.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.71,193.32,
BIOPSY: OROPHARYNX,82942800,CDM,983,RC,60300,HCPCS,Outpatient,,,136,136,,,,,,Other,Not Separately Reimbursable,143.04,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,143.04,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,135.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,135.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,135.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,77.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,77.08,143.04,
ASPIRATION/INJECTION THYROID CYST,82960300,CDM,983,RC,69005,HCPCS,Outpatient,,,61,61,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,56.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,56.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,56.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33,56.64,
"DRAINAGE EXT EAR, ABSC/HEMATOMA; COMPLIC",82969005,CDM,983,RC,69100,HCPCS,Outpatient,,,185,185,,,,,,Other,Not Separately Reimbursable,164.9,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,164.9,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,107.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.22,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,107.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.22,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,107.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,107.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,107.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,187.22,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,107.72,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,107.72,187.22,
BIOPSY EXTENAL EAR,82969100,CDM,983,RC,69200,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,78.93,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,78.93,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,31.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,31.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,31.38,78.93,
REMOVE FOREIGN BODY EAR,82969200,CDM,983,RC,69210,HCPCS,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,73.23,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,73.23,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,31.94,73.23,
Removal of ear wax from one or both ears,82969210,CDM,983,RC,69220,HCPCS,Outpatient,,,39,39,,,,,,Other,Not Separately Reimbursable,61.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,61.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,22.38,61.33,
"DEBRIDEMENT, MASTOIDECTOMY CAVITY, SIMPL",82969220,CDM,983,RC,69222,HCPCS,Outpatient,,,62,62,,,,,,Other,Not Separately Reimbursable,78.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,78.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,60.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,34.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,60.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,34.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,34.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,60.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,34.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.38,78.5,
"DEBRIDEMENT, MASTOIDECTOMY CAVITY, COMPL",82969222,CDM,983,RC,69420,HCPCS,Outpatient,,,159,159,,,,,,Other,Not Separately Reimbursable,122.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,122.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,91.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,157.93,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,91.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,157.93,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,91.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,91.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,91.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,157.93,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,91.2,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,91.2,157.93,
MYRINGOTOMY,82969420,CDM,983,RC,69433,HCPCS,Outpatient,,,141,141,,,,,,Other,Not Separately Reimbursable,122.32,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,122.32,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,81.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,139.61,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,81.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,139.61,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,81.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,81.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,81.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,139.61,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,81.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,81.15,139.61,
"TYMPANOSTOMY, LOCAL/TOPICAL ANESTHESIA",82969433,CDM,983,RC,69610,HCPCS,Outpatient,,,155,155,,,,,,Other,Not Separately Reimbursable,135.7,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,135.7,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,88.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,153.85,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,88.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,153.85,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,88.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,88.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,153.85,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,88.85,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.85,153.85,
TYMPANIC MEMBRANE RPR W OR W/O SITE PREP,82969610,CDM,983,RC,69620,HCPCS,Outpatient,,,346,346,,,,,,Other,Not Separately Reimbursable,300.9,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,300.9,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,195.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,339.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,195.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,339.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,195.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,195.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,195.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,339.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,195.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,195.18,339.53,
MYRINGOPLASTY,82969620,CDM,983,RC,92511,HCPCS,Outpatient,,,574,574,,,,,,Other,Not Separately Reimbursable,483.73,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,483.73,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,332.73,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,577.77,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,332.73,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,577.77,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,332.73,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,332.73,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,332.73,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,577.77,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,332.73,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,332.73,577.77,
NASOPHARYNGOSCOPY W/ENDOSCOPE,82992511,CDM,983,RC,92567,HCPCS,Outpatient,,,44,44,,,,,,Other,Not Separately Reimbursable,75.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,75.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.19,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.19,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.19,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.19,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,25.19,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.19,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.19,75.94,
TYMPANOMETRY,82992567,CDM,983,RC,99201,HCPCS,Outpatient,,,13,13,,,,,,Other,Not Separately Reimbursable,21.68,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,21.68,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,7.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,12.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,7.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,12.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,7.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,7.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,7.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,12.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,7.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,7.15,21.68,
OFFICE VISIT 10 MIN NEW,82999201,CDM,983,RC,99202,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,34.44,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,34.44,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.44,34.44,
"New patient office or other outpatient visit, typically 10 minutes",82999202,CDM,983,RC,99203,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,60.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,60.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33,60.3,
"New patient office or other outpatient visit, typically 30 min",82999203,CDM,983,RC,99204,HCPCS,Outpatient,,,91,91,,,,,,Other,Not Separately Reimbursable,89.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,89.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.23,96.86,
"New patient office of other outpatient visit, typically 45 min",82999204,CDM,983,RC,99205,HCPCS,Outpatient,,,153,153,,,,,,Other,Not Separately Reimbursable,129.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,129.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,154.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,154.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,154.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.62,154.99,
"New patient office of other outpatient visit, typically 60 min",82999205,CDM,983,RC,99211,HCPCS,Outpatient,,,223,223,,,,,,Other,Not Separately Reimbursable,163.15,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,163.15,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,210.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,210.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,210.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.42,210.34,
Outpatient visit of established patient not requiring a physician,82999211,CDM,983,RC,99212,HCPCS,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,19.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,19.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,10.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,10.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,10.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,5.51,19.16,
Outpatient visit of established patient requiring a physician,82999212,CDM,983,RC,99213,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,34.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,34.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,17.48,34.81,
"Established patient office or other outpatient visit, typically 15 minutes",82999213,CDM,983,RC,99214,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,48.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,48.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.62,69,
"Established patient office or other outpatient visit, typically 25 minutes",82999214,CDM,983,RC,99215,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,76.35,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,76.35,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.15,105.8,
"Established patient office or other outpatient, visit typically 40 minutes",82999215,CDM,983,RC,99441,HCPCS,Outpatient,,,131,131,,,,,,Other,Not Separately Reimbursable,113.7,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,113.7,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,150.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,150.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,150.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,67.08,150.65,
"Physician telephone patient service, 5-10 minutes of medical discussion",82999441,CDM,983,RC,99442,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,34.5,
"Physician telephone patient service, 11-20 minutes of medical discussion",82999442,CDM,983,RC,99443,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69,69,
"Physician telephone patient service, 21-30 minutes of medical discussion",82999443,CDM,983,RC,99201,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.35,102.35,
OFFICE VISIT 10 MIN NEW,95899201,CDM,983,RC,99202,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 20 MIN NEW,95899202,CDM,983,RC,99203,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 30 MIN NEW,95899203,CDM,983,RC,99204,HCPCS,Outpatient,,,91,91,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 45 MIN NEW,95899204,CDM,983,RC,99205,HCPCS,Outpatient,,,153,153,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 60 MIN NEW,95899205,CDM,983,RC,99211,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 5 MIN EST,95899211,CDM,983,RC,99212,HCPCS,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 10 MIN EST,95899212,CDM,983,RC,99213,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 15 MIN EST,95899213,CDM,983,RC,99214,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 25 MIN EST,95899214,CDM,983,RC,99215,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
OFFICE VISIT 40 MIN EST,95899215,CDM,983,RC,G0101,HCPCS,Outpatient,,,131,131,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,
PELVIC AND BREAST SCREENING EXAM,95900101,CDM,983,RC,G0102,HCPCS,Outpatient,,,33,33,,,,,,Other,Not Separately Reimbursable,37.93,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,37.93,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,18.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,32.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,18.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,32.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,18.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,18.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,18.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,32.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,18.66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,18.66,37.93,
Prostate cancer screening; digital rectal examination,95900102,CDM,983,RC,G0179,HCPCS,Outpatient,,,10,10,,,,,,Other,Not Separately Reimbursable,19.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,19.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.14,19.16,
PHY RECERT FOR MCR COVERED HH SVCS,95900179,CDM,983,RC,G0180,HCPCS,Outpatient,,,93,93,,,,,,Other,Not Separately Reimbursable,59.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,59.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,46.9,59.25,
PHY CERTIFICATION FOR MCR COVD HH SVCS,95900180,CDM,983,RC,G0181,HCPCS,Outpatient,,,120,120,,,,,,Other,Not Separately Reimbursable,70.72,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,70.72,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,59.13,70.72,
PHYS SUPERVISION OF HHA PATIENT,95900181,CDM,983,RC,G0296,HCPCS,Outpatient,,,243,243,,,,,,Other,Not Separately Reimbursable,118.23,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,118.23,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,119.06,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,119.06,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,119.06,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,118.23,119.06,
LDCT COUNSELING DETERMINATION VISIT,95900296,CDM,983,RC,G0396,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,2184.73,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,2184.73,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.84,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.84,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.84,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,29.84,2184.73,
ALCOH/SUBS STRUCT ASSES/INTERV 15-30MIN,95900396,CDM,983,RC,G0397,HCPCS,Outpatient,,,76,76,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.37,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.37,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.37,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,36.37,36.37,
ALCOH/SUBS STRUCT ASSESS/INTERV >30MIN,95900397,CDM,983,RC,G0402,HCPCS,Outpatient,,,150,150,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.12,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.12,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.12,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,76.12,76.12,
INITIAL PREVENTIVE PHYSICAL EXAM (IPPE),95900402,CDM,983,RC,G0438,HCPCS,Outpatient,,,287,287,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.79,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,151.79,151.79,
"ANNUAL WELLNESS VISIT,PPS INITIAL VISIT",95900438,CDM,983,RC,G0439,HCPCS,Outpatient,,,385,385,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,189.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,189.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,189.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,189.52,189.52,
"ANNUAL WELLNESS VISIT,PPS SUB VISIT",95900439,CDM,983,RC,G0442,HCPCS,Outpatient,,,261,261,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,147.55,147.55,
"ANNUAL ALCOHOL MISUSE SCREEN, 15 MIN",95900442,CDM,983,RC,G0443,HCPCS,Outpatient,,,21,21,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,10.5,
BEHAV COUN FACE TO FACE FOR ALCO MISUSE,95900443,CDM,983,RC,G0444,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.75,26.75,
"ANNUAL DEPRESSION SCREENING, 15 MIN",95900444,CDM,983,RC,G0447,HCPCS,Outpatient,,,21,21,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,10.5,10.5,
"BEHAV COUNS, FACE TO FACE, OBESITY,15MIN",95900447,CDM,983,RC,G0511,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,26.75,26.75,
"CHRONIC CARE MGMT SVC, 20 MIN",95900511,CDM,983,RC,G2012,HCPCS,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.7,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.7,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.7,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,43.7,43.7,
VIRTUAL CK IN; BRIEF 5-10 MIN,95902012,CDM,983,RC,10060,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.54,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.54,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.54,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,14.54,14.54,
Incision and drainage of abscess; simple or single and complex or multiple,95910060,CDM,983,RC,10061,HCPCS,Outpatient,,,116,116,,,,,,Other,Not Separately Reimbursable,87.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,87.1,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,120.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,68.7,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.7,120.26,
I&D ABCESS COMPLICATED OR MULTIPLE,95910061,CDM,983,RC,10120,HCPCS,Outpatient,,,213,213,,,,,,Other,Not Separately Reimbursable,158.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,158.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,212.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.29,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.29,212.07,
I&D REMOVE FB SIMPLE,95910120,CDM,983,RC,10121,HCPCS,Outpatient,,,123,123,,,,,,Other,Not Separately Reimbursable,102.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,102.64,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,121.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,121.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,121.26,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.15,121.26,
I&D REMOVE FB COMPLEX,95910121,CDM,983,RC,10160,HCPCS,Outpatient,,,222,222,,,,,,Other,Not Separately Reimbursable,196.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,196.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,214.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,214.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,214.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.84,214.35,
"Puncture aspiration of abscess, hematoma, bulla, or cyst",95910160,CDM,983,RC,11101,HCPCS,Outpatient,,,113,113,,,,,,Other,Not Separately Reimbursable,94.05,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,94.05,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.38,111.8,
BIOPSY SKIN ADD-ON,95911101,CDM,983,RC,11200,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,39.11,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,39.11,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,39.11,39.11,
"Removal of skin tags, multiple fibrocutaneous tags, any area",95911200,CDM,983,RC,11400,HCPCS,Outpatient,,,87,87,,,,,,Other,Not Separately Reimbursable,64.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,64.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,50.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,50.27,87.42,
EXC-BENIGN TRUNK/ARM/LEGS <0.5 CM,95911400,CDM,983,RC,11401,HCPCS,Outpatient,,,96,96,,,,,,Other,Not Separately Reimbursable,107.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,107.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,55.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.77,107.57,
Under Excision-Benign Lesions Procedures on the Skin 0.6-1 CM,95911401,CDM,983,RC,11402,HCPCS,Outpatient,,,124,124,,,,,,Other,Not Separately Reimbursable,126.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,126.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,70.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,70.84,126.52,
EXC-BENIGN TRUNK/ARM/LEGS 1.1-2.0 CM,95911402,CDM,983,RC,11403,HCPCS,Outpatient,,,137,137,,,,,,Other,Not Separately Reimbursable,143.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,143.18,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,133.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,133.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,133.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,78.28,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,78.28,143.18,
EXC-BENIGN TRUNK/ARM/LEGS 2.1-3.0 CM,95911403,CDM,983,RC,11404,HCPCS,Outpatient,,,178,178,,,,,,Other,Not Separately Reimbursable,166.14,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,166.14,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,172.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.38,172.68,
EXC-BENIGN TRUNK/ARM/LEGS 3.1-4.0,95911404,CDM,983,RC,11406,HCPCS,Outpatient,,,196,196,,,,,,Other,Not Separately Reimbursable,183.74,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,183.74,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,191.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,191.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,191.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,111,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,111,191.76,
EXC-BENIGN TRUNK/ARM/LEGS >4.0,95911406,CDM,983,RC,11600,HCPCS,Outpatient,,,300,300,,,,,,Other,Not Separately Reimbursable,220.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,220.42,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,291.88,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,291.88,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,291.88,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,168.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,168.68,291.88,
EXC-BENIGN TRUNK/ARM/LEGS <0.5CM,95911600,CDM,983,RC,11601,HCPCS,Outpatient,,,144,144,,,,,,Other,Not Separately Reimbursable,138.21,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,138.21,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.53,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,82.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,82.61,141.53,
EXC-BENIGN TRUNK/ARM/LEGS 0.6-1.0CM,95911601,CDM,983,RC,11602,HCPCS,Outpatient,,,179,179,,,,,,Other,Not Separately Reimbursable,163.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,163.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,171.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,171.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,171.36,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,100.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,100.15,171.36,
Excision-Malignant Lesions,95911602,CDM,983,RC,11603,HCPCS,Outpatient,,,196,196,,,,,,Other,Not Separately Reimbursable,176.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,176.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,185.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,185.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,185.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,108.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,108.68,185.75,
EXC-BENIGN TRUNK/ARM/LEGS 2.1-3.0CM,95911603,CDM,983,RC,11604,HCPCS,Outpatient,,,237,237,,,,,,Other,Not Separately Reimbursable,196.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,196.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,223.82,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,129.91,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,129.91,223.82,
EXC-BENIGN TRUNK/ARM/LEGS3.1-4.0CM,95911604,CDM,983,RC,11606,HCPCS,Outpatient,,,262,262,,,,,,Other,Not Separately Reimbursable,214.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,214.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,247.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,247.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,247.28,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,143.3,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,143.3,247.28,
EXC-BENIGN TRUNK/ARM/LEGS >4.0CM,95911606,CDM,983,RC,11730,HCPCS,Outpatient,,,390,390,,,,,,Other,Not Separately Reimbursable,271.53,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,271.53,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,372.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,372.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,372.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,215.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,215.06,372.23,
Separation and removal of the entire nail plate or a portion of nail plate,95911730,CDM,983,RC,11740,HCPCS,Outpatient,,,66,66,,,,,,Other,Not Separately Reimbursable,71.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,71.25,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.22,71.25,
EVACUATION OF SUBUNGAL HEMATOMA,95911740,CDM,983,RC,11760,HCPCS,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,36.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,36.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.46,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,21.22,36.67,
REPAIR OF NAIL BED,95911760,CDM,983,RC,11900,HCPCS,Outpatient,,,135,135,,,,,,Other,Not Separately Reimbursable,122.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,122.07,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,75.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,128.11,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,75.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,128.11,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,75.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,75.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,75.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,128.11,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,75.45,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,75.45,128.11,
Injections to remove up to 7 lesions on the skin,95911900,CDM,983,RC,11901,HCPCS,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,42.85,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,42.85,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.01,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.01,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,19.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,19.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.01,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,19.84,42.85,
ADDED SKIN LESIONS INJECTION,95911901,CDM,983,RC,12001,HCPCS,Outpatient,,,59,59,,,,,,Other,Not Separately Reimbursable,58.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,58.5,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,52.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,52.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,52.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.92,58.5,
"Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities",95912001,CDM,983,RC,12002,HCPCS,Outpatient,,,53,53,,,,,,Other,Not Separately Reimbursable,138.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,138.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,54.43,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.32,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.32,138.33,
REPAIR SUPERFICAL WOUND 2.6-7.5CM,95912002,CDM,983,RC,12004,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,150,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,150,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.15,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.15,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.15,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.11,150,
REPAIR SUPERFICAL WOUND 7.6-12.5CM,95912004,CDM,983,RC,12005,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,173.87,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,173.87,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,88.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,49.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.61,173.87,
REPAIR SUPERFICAL WOUND 12.6-20CM,95912005,CDM,983,RC,12006,HCPCS,Outpatient,,,116,116,,,,,,Other,Not Separately Reimbursable,215.91,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,215.91,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.91,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,64.84,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,64.84,215.91,
REPAIR SUPERFICAL WOUND 20.1-30CM,95912006,CDM,983,RC,12007,HCPCS,Outpatient,,,142,142,,,,,,Other,Not Separately Reimbursable,283.06,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,283.06,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,141.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,79.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.61,283.06,
REPAIR SUPERFICAL WOUND >30CM,95912007,CDM,983,RC,13121,HCPCS,Outpatient,,,179,179,,,,,,Other,Not Separately Reimbursable,315.14,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,315.14,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,99.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,175.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,99.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,175.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,99.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,99.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,99.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,175.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,99.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,99.22,315.14,
REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5CM,95913121,CDM,983,RC,17000,HCPCS,Outpatient,,,323,323,,,,,,Other,Not Separately Reimbursable,305.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,305.43,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,297.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,297.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,297.24,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,173.06,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,173.06,305.43,
Destruction of pre-cancerous lesion,95917000,CDM,983,RC,20526,HCPCS,Outpatient,,,62,62,,,,,,Other,Not Separately Reimbursable,56.48,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,56.48,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,36.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,36.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.33,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,36.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,36.38,62.33,
"INJECTION, THERAPEUTIC, CARPAL TUNNEL",95920526,CDM,983,RC,20550,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,38.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,38.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,38.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,38.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,38.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.94,68.05,
Injection of medication into a tendon or ligament,95920550,CDM,983,RC,20551,HCPCS,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,91.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,91.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,26.54,91.94,
Injection of medication into the tendon/ligament origin,95920551,CDM,983,RC,20552,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.23,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,26.54,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,26.54,63.31,
INJ TRIGGER POINT 1/2 MUSCL,95920552,CDM,983,RC,20553,HCPCS,Outpatient,,,46,46,,,,,,Other,Not Separately Reimbursable,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.42,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.61,63.31,
Injection of medication into an area that triggers pain,95920553,CDM,983,RC,20600,HCPCS,Outpatient,,,52,52,,,,,,Other,Not Separately Reimbursable,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,63.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,29.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,49.9,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.07,63.31,
Draining or injecting medication into a small joint/bursa without ultrasound,95920600,CDM,983,RC,20604,HCPCS,Outpatient,,,43,43,,,,,,Other,Not Separately Reimbursable,68.9,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,68.9,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,24.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,41.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,24.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,41.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,24.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,24.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,24.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,41.6,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,24.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,24.23,68.9,
ARTHROCESPIRATION/INJ;SM JNT/BUR W/US,95920604,CDM,983,RC,20605,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,31.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.89,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.89,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,31.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,31.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.89,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,31.15,53.89,
Draining or injecting medication into a large joint/bursa without ultrasound,95920605,CDM,983,RC,20606,HCPCS,Outpatient,,,45,45,,,,,,Other,Not Separately Reimbursable,78.34,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,78.34,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,25.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,25.15,78.34,
ARTHROCESPIRA/INJ; INTER JNT/BUR W/US,95920606,CDM,983,RC,20610,HCPCS,Outpatient,,,64,64,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,61.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,35.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,61.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,35.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,35.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,61.13,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,35.07,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.07,61.13,
Draining or injecting medication into a major joint/bursa without ultrasound,95920610,CDM,983,RC,20611,HCPCS,Outpatient,,,56,56,,,,,,Other,Not Separately Reimbursable,94.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,94.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,53.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.69,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.69,94.3,
ARTHROCESPIRA/INJ; MAJ JNT/BUR W/US,95920611,CDM,983,RC,20612,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.16,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.16,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,40.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.16,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,40.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,40.15,71.16,
Removal of fluid or injection of medication into a ganglion cyst,95920612,CDM,983,RC,21014,HCPCS,Outpatient,,,51,51,,,,,,Other,Not Separately Reimbursable,56.98,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,56.98,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,48.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27.92,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,27.92,56.98,
EXCIS SFT TISS TUMOR FACE/SCALP 2CM OR >,95921014,CDM,983,RC,25111,HCPCS,Outpatient,,,632,632,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,371.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,617.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,371.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,617.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,371.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,371.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,371.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,617.71,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,371.01,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,371.01,617.71,
EXCISION OF GANGLION CYST,95925111,CDM,983,RC,25505,HCPCS,Outpatient,,,384,384,,,,,,Other,Not Separately Reimbursable,342.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,342.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,383.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,383.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,383.69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,230.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,230.03,383.69,
CLSD TRMT OF RADIAL SHAFT FX;W/MANIP,95925505,CDM,983,RC,25609,HCPCS,Outpatient,,,542,542,,,,,,Other,Not Separately Reimbursable,467.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,467.31,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,316.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,550.72,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,316.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,550.72,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,316.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,316.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,316.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,550.72,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,316.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,316.22,550.72,
ORIF LEFT WRIST,95925609,CDM,983,RC,26210,HCPCS,Outpatient,,,1268,1268,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,749.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,1247.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,749.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,1247.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,749.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,749.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,749.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,1247.75,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,749.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,749.23,1247.75,
EXC BONE CYST/TUMOR OF FINGER,95926210,CDM,983,RC,26546,HCPCS,Outpatient,,,531,531,,,,,,Other,Not Separately Reimbursable,613.68,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,613.68,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,318.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,530.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,318.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,530.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,318.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,318.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,318.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,530.68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,318.14,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,318.14,613.68,
"REPAIR NON UNION, METACARPAL OR PHALANX",95926546,CDM,983,RC,26605,HCPCS,Outpatient,,,1174,1174,,,,,,Other,Not Separately Reimbursable,851.19,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,851.19,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,720.46,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,1218.89,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,720.46,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,1218.89,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,720.46,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,720.46,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,720.46,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,1218.89,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,720.46,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,720.46,1218.89,
CLSD TRMT OF METACARPAL FX W/MANIPULATIO,95926605,CDM,983,RC,26615,HCPCS,Outpatient,,,348,348,,,,,,Other,Not Separately Reimbursable,305.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,305.22,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,354.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,202.27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,202.27,354.55,
ORIF 5TH METACARPAL,95926615,CDM,983,RC,27372,HCPCS,Outpatient,,,693,693,,,,,,Other,Not Separately Reimbursable,489.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,489.67,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,411.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,681.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,411.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,681.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,411.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,411.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,411.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,681.31,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,411.57,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,411.57,681.31,
EXCISION FOREIGN BODY LEFT KNEE,95927372,CDM,983,RC,29065,HCPCS,Outpatient,,,481,481,,,,,,Other,Not Separately Reimbursable,477.82,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,477.82,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,276.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,476.17,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,276.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,476.17,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,276.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,276.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,276.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,476.17,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,276.1,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,276.1,477.82,
APPLICATION OF LONG ARM CAST,95929065,CDM,983,RC,29075,HCPCS,Outpatient,,,82,82,,,,,,Other,Not Separately Reimbursable,81.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,81.52,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,46.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,46.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,80.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.18,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.18,81.52,
APPLICATION OF FOREARM CAST,95929075,CDM,983,RC,29085,HCPCS,Outpatient,,,75,75,,,,,,Other,Not Separately Reimbursable,74.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,74.03,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,74.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,74.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,74.05,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,41.77,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,41.77,74.05,
APPLICATION OF HAND/WRIST CAST,95929085,CDM,983,RC,29105,HCPCS,Outpatient,,,81,81,,,,,,Other,Not Separately Reimbursable,77.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,77.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,79.04,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,45.47,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,45.47,79.04,
APPLICATION OF LONG ARM SPLINT,95929105,CDM,983,RC,29125,HCPCS,Outpatient,,,71,71,,,,,,Other,Not Separately Reimbursable,77.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,77.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.41,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.41,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.41,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,28.71,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,28.71,77.76,
APPLICATION OF FOREARM SPLINT,95929125,CDM,983,RC,29130,HCPCS,Outpatient,,,47,47,,,,,,Other,Not Separately Reimbursable,59.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,59.76,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,47.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,47.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,47.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,27,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,27,59.76,
APPLICATION OF FINGER SPLINT,95929130,CDM,983,RC,29345,HCPCS,Outpatient,,,35,35,,,,,,Other,Not Separately Reimbursable,47.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,47.58,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,35.39,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,19.82,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,19.82,47.58,
APPLICATION OF LONG LEG CAST(THIGH-TOES),95929345,CDM,983,RC,29405,HCPCS,Outpatient,,,122,122,,,,,,Other,Not Separately Reimbursable,117.44,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,117.44,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,67.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,117.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,67.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,117.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,67.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,67.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,67.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,117.44,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,67.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,67.38,117.44,
APPL OF SHORT LEG CAST BELOW KNEE TO TOE,95929405,CDM,983,RC,29505,HCPCS,Outpatient,,,72,72,,,,,,Other,Not Separately Reimbursable,78.61,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,78.61,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,39.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,39.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,39.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,39.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,39.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,68,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,39.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,39.22,78.61,
APPLICATION OF LONG LEG SPLINT,95929505,CDM,983,RC,29515,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,77.99,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,77.99,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,60.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,60.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,60.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,34.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.61,77.99,
APPLICATION OF LOWER LEG SPLINT,95929515,CDM,983,RC,43239,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,66.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,66.57,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,57.74,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,57.74,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,57.74,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33.22,66.57,
"Biopsy of the esophagus, stomach, and/or upper small bowel using an endoscope",95943239,CDM,983,RC,45378,HCPCS,Outpatient,,,328,328,,,,,,Other,Not Separately Reimbursable,275.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,275.75,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,93.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,160.08,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,93.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,160.08,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,93.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,93.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,93.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,160.08,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,93.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,93.22,275.75,
Diagnostic examination of large bowel using an endoscope,95945378,CDM,983,RC,45380,HCPCS,Outpatient,,,441,441,,,,,,Other,Not Separately Reimbursable,367.11,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,367.11,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,124.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,214.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,214.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,124.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,214.52,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,124.61,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,124.61,367.11,
Biopsy of large bowel using an endoscope,95945380,CDM,983,RC,64721,HCPCS,Outpatient,,,478,478,,,,,,Other,Not Separately Reimbursable,390.39,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,390.39,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,135.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.84,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,135.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.84,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,135.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,135.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,135.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,232.84,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,135.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,135.22,390.39,
Release of the transverse carpal ligament,95964721,CDM,983,RC,69200,HCPCS,Outpatient,,,514,514,,,,,,Other,Not Separately Reimbursable,396.88,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,396.88,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,296.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,514.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,296.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,514.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,296.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,296.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,296.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,514.48,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,296.11,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,296.11,514.48,
REM FOREIGN BODY FROM EXT AUDITORY CANAL,95969200,CDM,983,RC,69210,HCPCS,Outpatient,,,57,57,,,,,,Other,Not Separately Reimbursable,73.23,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,73.23,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.64,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,31.94,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,31.94,73.23,
Removal of ear wax from one or both ears,95969210,CDM,983,RC,93010,HCPCS,Outpatient,,,40,40,,,,,,Other,Not Separately Reimbursable,61.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,61.33,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,38.55,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,22.38,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,22.38,61.33,
EKG INTERPRETATION & REPORT,95993010,CDM,985,RC,99201,HCPCS,Outpatient,,,19,19,,,,,,Other,Not Separately Reimbursable,10.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,10.46,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,9.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,9.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,9.38,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,5.76,10.46,
OFFICE VISIT 10 MIN NEW,95999201,CDM,983,RC,99202,HCPCS,Outpatient,,,32,32,,,,,,Other,Not Separately Reimbursable,34.44,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,34.44,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.44,34.44,
"New patient office or other outpatient visit, typically 10 minutes",95999202,CDM,983,RC,99203,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,60.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,60.3,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,55.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,33,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,33,60.3,
"New patient office or other outpatient visit, typically 30 min",95999203,CDM,983,RC,99204,HCPCS,Outpatient,,,91,91,,,,,,Other,Not Separately Reimbursable,89.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,89.09,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,96.86,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,51.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,51.23,96.86,
"New patient office of other outpatient visit, typically 45 min",95999204,CDM,983,RC,99205,HCPCS,Outpatient,,,153,153,,,,,,Other,Not Separately Reimbursable,129.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,129.2,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,154.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,154.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,154.99,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,87.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,87.62,154.99,
"New patient office of other outpatient visit, typically 60 min",95999205,CDM,983,RC,99211,HCPCS,Outpatient,,,200,200,,,,,,Other,Not Separately Reimbursable,163.15,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,163.15,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,210.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,210.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,210.34,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.42,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.42,210.34,
Outpatient visit of established patient not requiring a physician,95999211,CDM,983,RC,99212,HCPCS,Outpatient,,,11,11,,,,,,Other,Not Separately Reimbursable,19.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,19.16,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,10.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,10.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,10.14,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,5.51,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,5.51,19.16,
Outpatient visit of established patient requiring a physician,95999212,CDM,983,RC,99213,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,34.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,34.81,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,17.48,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,17.48,34.81,
"Established patient office or other outpatient visit, typically 15 minutes",95999213,CDM,983,RC,99214,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,48.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,48.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,29.62,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.62,69,
"Established patient office or other outpatient visit, typically 25 minutes",95999214,CDM,983,RC,99215,HCPCS,Outpatient,,,92,92,,,,,,Other,Not Separately Reimbursable,76.35,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,76.35,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,105.8,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,46.15,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,46.15,105.8,
"Established patient office or other outpatient, visit typically 40 minutes",95999215,CDM,983,RC,99304,HCPCS,Outpatient,,,131,131,,,,,,Other,Not Separately Reimbursable,113.7,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,113.7,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,150.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,150.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,150.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,67.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,67.08,150.65,
"INITIAL NURSING FACILITY CARE, 25 MIN",95999304,CDM,983,RC,99305,HCPCS,Outpatient,,,206,206,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,61.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,92.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,61.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,92.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,61.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,61.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,61.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,92.87,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,61.68,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,61.68,92.87,
"INITIAL NURSING FACILTY CARE, 35 MIN",95999305,CDM,983,RC,99306,HCPCS,Outpatient,,,294,294,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,89.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,153.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,89.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,153.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,89.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,89.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,89.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,153.76,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,89.03,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,89.03,153.76,
"INITIAL NURSING FACILTY CARE, 45 MIN",95999306,CDM,983,RC,99307,HCPCS,Outpatient,,,376,376,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,114.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,209.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,209.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,114.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,209.65,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,114.23,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,114.23,209.65,
"SUBS NURSING FACILTY CARE, 10 MIN",95999307,CDM,983,RC,99308,HCPCS,Outpatient,,,100,100,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,45.29,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,45.29,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,30.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,45.29,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,30.24,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,30.24,45.29,
"SUBS NURSING FACILTY CARE, 15 MIN",95999308,CDM,983,RC,99309,HCPCS,Outpatient,,,156,156,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,47.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,85.62,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,47.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,85.62,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,47.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,47.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,47.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,85.62,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,47.76,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,47.76,85.62,
"SUBS NURSING FACILTY CARE, 25 MIN",95999309,CDM,983,RC,99310,HCPCS,Outpatient,,,206,206,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,62.88,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,62.88,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,62.88,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.88,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,62.88,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,122.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,62.88,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,62.88,122.27,
"SUBS NURSING FACILTY CARE, 35 MIN",95999310,CDM,983,RC,99315,HCPCS,Outpatient,,,307,307,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,92.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,176.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,92.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,176.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,92.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,92.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,92.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,176.27,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,92.63,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,92.63,176.27,
NF DISCHARGE MGMT; 30MIN OR LESS,95999315,CDM,983,RC,99316,HCPCS,Outpatient,,,164,164,,,,,,Other,Not Separately Reimbursable,59.71,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,59.71,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,50.16,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,93.77,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,50.16,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,93.77,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,50.16,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,50.16,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,50.16,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,93.77,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,50.16,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,50.16,93.77,
NF DISCHARGE MGMT; MORE THAN 30M,95999316,CDM,983,RC,99318,HCPCS,Outpatient,,,239,239,,,,,,Other,Not Separately Reimbursable,77.63,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,77.63,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,71.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,151.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,151.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,71.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,151.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,71.75,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,71.75,151.56,
E&M INVOLVING ANNUAL NF ASSESSMENT,95999318,CDM,983,RC,99354,HCPCS,Outpatient,,,217,217,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,66,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,66,66,
"PROLONGED E&M OR PSYCHO SVC, 1ST HR",95999354,CDM,983,RC,99355,HCPCS,Outpatient,,,276,276,,,,,,Other,Not Separately Reimbursable,115.37,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,115.37,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,60.67,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,60.67,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,60.67,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,60.67,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,60.67,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,60.67,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,60.67,115.37,
"PROLONGED E&M OR PSYCHO SVC, ADDL 30M",95999355,CDM,983,RC,99406,HCPCS,Outpatient,,,207,207,,,,,,Other,Not Separately Reimbursable,109.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,109.94,100,,,fee schedule,Pays at 100% of BCBS fee schedule for Outpatient Setting,,,,,Other,Not Separately reimbursable,56.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,56.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,56.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,56.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,56.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,56.53,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,56.53,109.94,
"SMOKE/TOB CESS CNSL INTERM, ASYM 3-10MIN",95999406,CDM,983,RC,99407,HCPCS,Outpatient,,,34,34,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,13.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,8.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,13.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,8.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,8.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,8.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,13.78,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,8.08,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,8.08,13.78,
"SMOKE/TOB CESS CNSL INTENS, ASYMP >10M",95999407,CDM,983,RC,99441,HCPCS,Outpatient,,,70,70,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,15.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,15.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,15.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,15.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,29.07,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,15.26,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,15.26,29.07,
"Physician telephone patient service, 5-10 minutes of medical discussion",95999441,CDM,983,RC,99442,HCPCS,Outpatient,,,30,30,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,34.5,34.5,
"Physician telephone patient service, 11-20 minutes of medical discussion",95999442,CDM,983,RC,99443,HCPCS,Outpatient,,,60,60,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,69,69,
"Physician telephone patient service, 21-30 minutes of medical discussion",95999443,CDM,983,RC,99490,HCPCS,Outpatient,,,89,89,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,102.35,102.35,
"CHRONIC CARE MGMT SVC, 20 MIN",95999490,CDM,983,RC,99495,HCPCS,Outpatient,,,38,38,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.7,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.7,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,,,,,Other,Not Separately reimbursable,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,43.7,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,21.22,100,,,fee schedule,Pays at 100% of CMS Phsician fee Schedule,21.22,43.7,
TRANS CARE MGMT 14 DAY DISCH,95999495,CDM,983,RC,99496,HCPCS,Outpatient,,,129,129,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.35,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,148.35,148.35,
TRANS CARE MGMT 7 DAY DISCH,95999496,CDM,983,RC,99497,HCPCS,Outpatient,,,188,188,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216.2,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216.2,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216.2,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,216.2,216.2,
"ADVANCED CARE PLANNING, 30 MIN",95999497,CDM,983,RC,99498,HCPCS,Outpatient,,,93,93,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.18,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.18,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.18,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,87.18,87.18,
ADVANCED CARE PLANNING EACH ADD'L 30 MIN,95999498,CDM,983,RC,99498,HCPCS,Outpatient,,,88,88,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,,,,,Other,Not Separately reimbursable,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.56,115,,,fee schedule,Pays at 115% of CMS Physician fee schedule,,,,,Other,Pays at EAPG rate. See EAPG rows for rates,82.56,82.56,
Heart transplant or implant of heart assist system w MCC,1,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,73579.02,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,77451.6,100,MS-DRG,61961.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77451.6,73579.02,
Heart transplant or implant of heart assist system w/o MCC,2,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,73579.02,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,77451.6,100,MS-DRG,61961.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,77451.6,73579.02,
"ECMO or trach w MV 96+ hrs or PDX exc face, mouth & neck w maj O.R.",3,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,114235.98,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,120248.4,100,MS-DRG,96198.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,120248.4,114235.98,
"Trach w MV 96+ hrs or PDX exc face, mouth & neck w/o maj O.R.",4,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,68563.02,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,72171.6,100,MS-DRG,57737.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,72171.6,68563.02,
Liver transplant w MCC or intestinal transplant,5,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,65363.04,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,68803.2,100,MS-DRG,55042.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68803.2,65363.04,
Liver transplant w/o MCC,6,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,65363.04,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,68803.2,100,MS-DRG,55042.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,68803.2,65363.04,
Lung transplant,7,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,54247.47,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,57102.6,100,MS-DRG,45682.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,57102.6,54247.47,
Simultaneous pancreas/kidney transplant,8,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,33288,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,35040,100,MS-DRG,28032,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,35040,33288,
Pancreas transplant,10,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,32953.41,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,34687.8,100,MS-DRG,27750.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,34687.8,32953.41,
"Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with MCC",11,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18616.2,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19596,100,MS-DRG,15676.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19596,18616.2,
"Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with CC",12,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18616.2,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19596,100,MS-DRG,15676.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19596,18616.2,
"Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy without CC/MCC",13,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18616.2,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19596,100,MS-DRG,15676.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19596,18616.2,
Allogeneic Bone Marrow Transplant,14,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,64307.97,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,67692.6,100,MS-DRG,54154.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67692.6,64307.97,
Autologous Bone Marrow Transplant with CC/MCC or T-cell Immunotherapy,16,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,64307.97,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,67692.6,100,MS-DRG,54154.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67692.6,64307.97,
Autologous Bone Marrow Transplant without CC/MCC,17,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,64307.97,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,67692.6,100,MS-DRG,54154.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,67692.6,64307.97,
Intracranial vascular procedures w PDX hemorrhage w MCC,20,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,41156.85,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,43323,100,MS-DRG,34658.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43323,41156.85,
Intracranial vascular procedures w PDX hemorrhage w CC,21,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,41156.85,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,43323,100,MS-DRG,34658.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43323,41156.85,
Intracranial vascular procedures w PDX hemorrhage w/o CC/MCC,22,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,41156.85,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,43323,100,MS-DRG,34658.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43323,41156.85,
Craniotomy w major device implant  or acute CNS PDX w MCC or chemotherapy implant or epilepsy w neurostimulator,23,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,25410.03,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,26747.4,100,MS-DRG,21397.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26747.4,25410.03,
Craniotomy w major device implant or acute complex CNS PDX w/o MCC,24,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,25410.03,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,26747.4,100,MS-DRG,21397.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26747.4,25410.03,
Craniotomy & endovascular intracranial procedures w MCC,25,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,21723.27,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,22866.6,100,MS-DRG,18293.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22866.6,21723.27,
Craniotomy & endovascular intracranial procedures w CC,26,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,21723.27,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,22866.6,100,MS-DRG,18293.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22866.6,21723.27,
Craniotomy & endovascular intracranial procedures w/o CC/MCC,27,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,20297.7,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,21366,100,MS-DRG,17092.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21366,20297.7,
Spinal procedures w MCC,28,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,17414.64,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,18331.2,100,MS-DRG,14664.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18331.2,17414.64,
Spinal procedures w CC or spinal neurostimulators,29,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,17414.64,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,18331.2,100,MS-DRG,14664.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18331.2,17414.64,
Spinal procedures w/o CC/MCC,30,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8254.74,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8689.2,100,MS-DRG,6951.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8689.2,8254.74,
Ventricular shunt procedures w MCC,31,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12841.53,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13517.4,100,MS-DRG,10813.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13517.4,12841.53,
Ventricular shunt procedures w CC,32,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12841.53,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13517.4,100,MS-DRG,10813.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13517.4,12841.53,
Ventricular shunt procedures w/o CC/MCC,33,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6849.69,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7210.2,100,MS-DRG,5768.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7210.2,6849.69,
Carotid artery stent procedure w MCC,34,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10171.08,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10706.4,100,MS-DRG,8565.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10706.4,10171.08,
Carotid artery stent procedure w CC,35,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10171.08,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10706.4,100,MS-DRG,8565.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10706.4,10171.08,
Carotid artery stent procedure w/o CC/MCC,36,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10171.08,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10706.4,100,MS-DRG,8565.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10706.4,10171.08,
Extracranial procedures w MCC,37,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9506.46,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10006.8,100,MS-DRG,8005.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10006.8,9506.46,
Extracranial procedures w CC,38,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9506.46,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10006.8,100,MS-DRG,8005.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10006.8,9506.46,
Extracranial procedures w/o CC/MCC,39,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6126.36,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6448.8,100,MS-DRG,5159.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6448.8,6126.36,
Periph & cranial nerve & other nerv syst proc w MCC,40,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7903.62,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8319.6,100,MS-DRG,6655.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8319.6,7903.62,
Periph & cranial nerve & other nerv syst proc w CC or peripheral neurostimulators ,41,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7903.62,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8319.6,100,MS-DRG,6655.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8319.6,7903.62,
Periph & cranial nerve & other nerv syst proc w/o CC/MCC,42,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4254.48,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4478.4,100,MS-DRG,3582.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4478.4,4254.48,
Spinal disorders & injuries w CC/MCC,52,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8113.95,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8541,100,MS-DRG,6832.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8541,8113.95,
Spinal disorders & injuries w/o CC/MCC,53,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8113.95,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8541,100,MS-DRG,6832.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8541,8113.95,
Nervous system neoplasms w MCC,54,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6453.54,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6793.2,100,MS-DRG,5434.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6793.2,6453.54,
Nervous system neoplasms w/o MCC,55,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5322.66,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5602.8,100,MS-DRG,4482.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5602.8,5322.66,
Degenerative nervous system disorders w MCC,56,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5700.57,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6000.6,100,MS-DRG,4800.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6000.6,5700.57,
Degenerative nervous system disorders w/o MCC,57,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5700.57,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6000.6,100,MS-DRG,4800.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6000.6,5700.57,
Multiple sclerosis & cerebellar ataxia w MCC,58,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5580.3,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5874,100,MS-DRG,4699.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5874,5580.3,
Multiple sclerosis & cerebellar ataxia w CC,59,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5580.3,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5874,100,MS-DRG,4699.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5874,5580.3,
Multiple sclerosis & cerebellar ataxia w/o CC/MCC,60,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5580.3,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5874,100,MS-DRG,4699.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5874,5580.3,
"Ischemic stroke, precerbral occlusion or transient ischemia w thrombolytic agent w MCC",61,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12809.61,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13483.8,100,MS-DRG,10787.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13483.8,12809.61,
"Ischemic stroke, precerbral occlusion or transient ischemia w thrombolytic agent w CC",62,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12809.61,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13483.8,100,MS-DRG,10787.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13483.8,12809.61,
"Ischemic stroke, precerbral occlusion or transient ischemia w thrombolytic agent w/o CC/MCC",63,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12809.61,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13483.8,100,MS-DRG,10787.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13483.8,12809.61,
Intracranial hemorrhage or cerebral infarction w MCC,64,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7491.51,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7885.8,100,MS-DRG,6308.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7885.8,7491.51,
Intracranial hemorrhage or cerebral infarction w CC,65,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7491.51,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7885.8,100,MS-DRG,6308.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7885.8,7491.51,
Intracranial hemorrhage or cerebral infarction w/o CC/MCC,66,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7491.51,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7885.8,100,MS-DRG,6308.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7885.8,7491.51,
Nonspecific cva & precerebral occlusion w/o infarct w MCC,67,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3557.37,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3744.6,100,MS-DRG,2995.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3744.6,3557.37,
Nonspecific cva & precerebral occlusion w/o infarct w/o MCC,68,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3557.37,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3744.6,100,MS-DRG,2995.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3744.6,3557.37,
Transient ischemia w/o thrombolytic,69,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4125.66,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4342.8,100,MS-DRG,3474.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4342.8,4125.66,
Nonspecific cerebrovascular disorders w MCC,70,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5153.94,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5425.2,100,MS-DRG,4340.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5425.2,5153.94,
Nonspecific cerebrovascular disorders w CC,71,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5153.94,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5425.2,100,MS-DRG,4340.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5425.2,5153.94,
Nonspecific cerebrovascular disorders w/o CC/MCC,72,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3877.14,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4081.2,100,MS-DRG,3264.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4081.2,3877.14,
Cranial & peripheral nerve disorders w MCC,73,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4312.62,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4539.6,100,MS-DRG,3631.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4539.6,4312.62,
Cranial & peripheral nerve disorders w/o MCC,74,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3732.93,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3929.4,100,MS-DRG,3143.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3929.4,3732.93,
Viral meningitis w CC/MCC,75,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7491.51,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7885.8,100,MS-DRG,6308.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7885.8,7491.51,
Viral meningitis w/o CC/MCC,76,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7491.51,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7885.8,100,MS-DRG,6308.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7885.8,7491.51,
Hypertensive encephalopathy w MCC,77,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4039.02,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4251.6,100,MS-DRG,3401.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4251.6,4039.02,
Hypertensive encephalopathy w CC,78,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4039.02,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4251.6,100,MS-DRG,3401.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4251.6,4039.02,
Hypertensive encephalopathy w/o CC/MCC,79,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4039.02,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4251.6,100,MS-DRG,3401.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4251.6,4039.02,
Nontraumatic stupor & coma w MCC,80,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6406.23,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6743.4,100,MS-DRG,5394.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6743.4,6406.23,
Nontraumatic stupor & coma w/o MCC,81,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6406.23,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6743.4,100,MS-DRG,5394.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6743.4,6406.23,
"Traumatic stupor & coma, coma >1 hr w MCC",82,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8917.65,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9387,100,MS-DRG,7509.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9387,8917.65,
"Traumatic stupor & coma, coma >1 hr w CC",83,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8917.65,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9387,100,MS-DRG,7509.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9387,8917.65,
"Traumatic stupor & coma, coma >1 hr w/o CC/MCC",84,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8917.65,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9387,100,MS-DRG,7509.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9387,8917.65,
"Traumatic stupor & coma, coma <1 hr w MCC",85,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5370.54,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5653.2,100,MS-DRG,4522.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5653.2,5370.54,
"Traumatic stupor & coma, coma <1 hr w CC",86,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5370.54,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5653.2,100,MS-DRG,4522.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5653.2,5370.54,
"Traumatic stupor & coma, coma <1 hr w/o CC/MCC",87,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3683.34,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3877.2,100,MS-DRG,3101.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3877.2,3683.34,
Concussion w MCC,88,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3067.17,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3228.6,100,MS-DRG,2582.88,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3228.6,3067.17,
Concussion w CC,89,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3067.17,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3228.6,100,MS-DRG,2582.88,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3228.6,3067.17,
Concussion w/o CC/MCC,90,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2316.48,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2438.4,100,MS-DRG,1950.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2438.4,2316.48,
Other disorders of nervous system w MCC,91,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5563.77,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5856.6,100,MS-DRG,4685.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5856.6,5563.77,
Other disorders of nervous system w CC,92,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5563.77,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5856.6,100,MS-DRG,4685.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5856.6,5563.77,
Other disorders of nervous system w/o CC/MCC,93,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4208.31,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4429.8,100,MS-DRG,3543.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4429.8,4208.31,
Bacterial & tuberculous infections of nervous system w MCC,94,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8029.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8452.2,100,MS-DRG,6761.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8452.2,8029.59,
Bacterial & tuberculous infections of nervous system w CC,95,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8029.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8452.2,100,MS-DRG,6761.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8452.2,8029.59,
Bacterial & tuberculous infections of nervous system w/o CC/MCC,96,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8029.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8452.2,100,MS-DRG,6761.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8452.2,8029.59,
Non-bacterial infect of nervous sys exc viral meningitis w MCC,97,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8029.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8452.2,100,MS-DRG,6761.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8452.2,8029.59,
Non-bacterial infect of nervous sys exc viral meningitis w CC,98,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8029.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8452.2,100,MS-DRG,6761.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8452.2,8029.59,
Non-bacterial infect of nervous sys exc viral meningitis w/o CC/MCC,99,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8029.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8452.2,100,MS-DRG,6761.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8452.2,8029.59,
Seizures w MCC,100,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4355.94,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4585.2,100,MS-DRG,3668.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4585.2,4355.94,
Seizures w/o MCC,101,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3565.35,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3753,100,MS-DRG,3002.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3753,3565.35,
Headaches w MCC,102,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3565.35,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3753,100,MS-DRG,3002.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3753,3565.35,
Headaches w/o MCC,103,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3146.4,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3312,100,MS-DRG,2649.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3312,3146.4,
Orbital procedures w CC/MCC,113,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3811.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4012.2,100,MS-DRG,3209.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4012.2,3811.59,
Orbital procedures w/o CC/MCC,114,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3811.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4012.2,100,MS-DRG,3209.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4012.2,3811.59,
Extraocular procedures except orbit,115,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2355.81,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2479.8,100,MS-DRG,1983.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2479.8,2355.81,
Intraocular procedures w CC/MCC,116,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4047.57,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4260.6,100,MS-DRG,3408.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4260.6,4047.57,
Intraocular procedures w/o CC/MCC,117,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3728.94,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3925.2,100,MS-DRG,3140.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3925.2,3728.94,
Acute major eye infections w CC/MCC,121,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3645.15,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3837,100,MS-DRG,3069.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3837,3645.15,
Acute major eye infections w/o CC/MCC,122,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3645.15,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3837,100,MS-DRG,3069.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3837,3645.15,
Neurological eye disorders,123,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3081.99,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3244.2,100,MS-DRG,2595.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3244.2,3081.99,
Other disorders of the eye w  MCC,124,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3425.13,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3605.4,100,MS-DRG,2884.32,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3605.4,3425.13,
Other disorders of the eye w/o  MCC,125,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2386.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2512.2,100,MS-DRG,2009.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2512.2,2386.59,
Major head & neck procedures w CC/MCC or major device,129,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,16382.94,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,17245.2,100,MS-DRG,13796.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17245.2,16382.94,
Major head & neck procedures w/o CC/MCC,130,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,16382.94,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,17245.2,100,MS-DRG,13796.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17245.2,16382.94,
Cranial/facial procedures w CC/MCC,131,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9291,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9780,100,MS-DRG,7824,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9780,9291,
Cranial/facial procedures w/o CC/MCC,132,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6870.78,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7232.4,100,MS-DRG,5785.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7232.4,6870.78,
"Other ear, nose, mouth & throat O.R. procedures w CC/MCC",133,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6622.26,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6970.8,100,MS-DRG,5576.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6970.8,6622.26,
"Other ear, nose, mouth & throat O.R. procedures w/o CC/MCC",134,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4398.69,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4630.2,100,MS-DRG,3704.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4630.2,4398.69,
Sinus & mastoid procedures w CC/MCC,135,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3926.73,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4133.4,100,MS-DRG,3306.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4133.4,3926.73,
Sinus & mastoid procedures w/o CC/MCC,136,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3519.75,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3705,100,MS-DRG,2964,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3705,3519.75,
Mouth procedures w CC/MCC,137,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5233.74,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5509.2,100,MS-DRG,4407.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5509.2,5233.74,
Mouth procedures w/o CC/MCC,138,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3750.6,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3948,100,MS-DRG,3158.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3948,3750.6,
Salivary gland procedures,139,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4008.81,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4219.8,100,MS-DRG,3375.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4219.8,4008.81,
"Ear, nose, mouth & throat malignancy w MCC",146,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5568.33,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5861.4,100,MS-DRG,4689.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5861.4,5568.33,
"Ear, nose, mouth & throat malignancy w CC",147,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5568.33,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5861.4,100,MS-DRG,4689.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5861.4,5568.33,
"Ear, nose, mouth & throat malignancy w/o CC/MCC",148,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5568.33,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5861.4,100,MS-DRG,4689.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5861.4,5568.33,
Dysequilibrium,149,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2565,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2700,100,MS-DRG,2160,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2700,2565,
Epistaxis w MCC,150,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2362.08,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2486.4,100,MS-DRG,1989.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2486.4,2362.08,
Epistaxis w/o MCC,151,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2362.08,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2486.4,100,MS-DRG,1989.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2486.4,2362.08,
Otitis media & URI w MCC,152,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5336.91,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5617.8,100,MS-DRG,4494.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5617.8,5336.91,
Otitis media & URI w/o MCC,153,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3751.74,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3949.2,100,MS-DRG,3159.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3949.2,3751.74,
Nasal trauma & deformity w MCC,154,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3445.65,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3627,100,MS-DRG,2901.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3627,3445.65,
Nasal trauma & deformity w CC,155,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3445.65,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3627,100,MS-DRG,2901.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3627,3445.65,
Nasal trauma & deformity w/o CC/MCC,156,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2973.12,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3129.6,100,MS-DRG,2503.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3129.6,2973.12,
Dental & Oral Diseases w MCC,157,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4073.79,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4288.2,100,MS-DRG,3430.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4288.2,4073.79,
Dental & Oral Diseases w CC,158,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4073.79,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4288.2,100,MS-DRG,3430.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4288.2,4073.79,
Dental & Oral Diseases w/o CC/MCC,159,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2399.13,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2525.4,100,MS-DRG,2020.32,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2525.4,2399.13,
Major chest procedures w MCC,163,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,16972.32,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,17865.6,100,MS-DRG,14292.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17865.6,16972.32,
Major chest procedures w CC,164,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,16972.32,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,17865.6,100,MS-DRG,14292.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17865.6,16972.32,
Major chest procedures w/o CC/MCC,165,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,16972.32,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,17865.6,100,MS-DRG,14292.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17865.6,16972.32,
Other resp system O.R. procedures w MCC,166,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14627.91,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,15397.8,100,MS-DRG,12318.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15397.8,14627.91,
Other resp system O.R. procedures w CC,167,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14627.91,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,15397.8,100,MS-DRG,12318.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15397.8,14627.91,
Other resp system O.R. procedures w/o CC/MCC,168,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9538.38,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10040.4,100,MS-DRG,8032.32,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10040.4,9538.38,
Pulmonary embolism w MCC or Acute Cor Pulmonale,175,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8434.86,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8878.8,100,MS-DRG,7103.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8878.8,8434.86,
Pulmonary embolism w/o MCC,176,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8434.86,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8878.8,100,MS-DRG,7103.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8878.8,8434.86,
Respiratory infections & inflammations w MCC,177,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11026.08,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11606.4,100,MS-DRG,9285.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11606.4,11026.08,
Respiratory infections & inflammations w CC,178,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11026.08,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11606.4,100,MS-DRG,9285.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11606.4,11026.08,
Respiratory infections & inflammations w/o CC/MCC,179,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8200.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8632.2,100,MS-DRG,6905.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8632.2,8200.59,
Respiratory neoplasms w MCC,180,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6417.06,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6754.8,100,MS-DRG,5403.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6754.8,6417.06,
Respiratory neoplasms w CC,181,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6417.06,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6754.8,100,MS-DRG,5403.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6754.8,6417.06,
Respiratory neoplasms w/o CC/MCC,182,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6417.06,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6754.8,100,MS-DRG,5403.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6754.8,6417.06,
Major chest trauma w MCC,183,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4786.29,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5038.2,100,MS-DRG,4030.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5038.2,4786.29,
Major chest trauma w CC,184,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4786.29,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5038.2,100,MS-DRG,4030.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5038.2,4786.29,
Major chest trauma w/o CC/MCC,185,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3374.4,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3552,100,MS-DRG,2841.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3552,3374.4,
Pleural effusion w MCC,186,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6381.72,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6717.6,100,MS-DRG,5374.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6717.6,6381.72,
Pleural effusion w CC,187,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6381.72,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6717.6,100,MS-DRG,5374.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6717.6,6381.72,
Pleural effusion w/o CC/MCC,188,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5563.77,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5856.6,100,MS-DRG,4685.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5856.6,5563.77,
Pulmonary edema & respiratory failure,189,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10303.32,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10845.6,100,MS-DRG,8676.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10845.6,10303.32,
Chronic obstructive pulmonary disease w MCC,190,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6137.76,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6460.8,100,MS-DRG,5168.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6460.8,6137.76,
Chronic obstructive pulmonary disease w CC,191,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6137.76,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6460.8,100,MS-DRG,5168.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6460.8,6137.76,
Chronic obstructive pulmonary disease w/o CC/MCC,192,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6137.76,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6460.8,100,MS-DRG,5168.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6460.8,6137.76,
Simple pneumonia & pleurisy w MCC,193,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6644.49,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6994.2,100,MS-DRG,5595.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6994.2,6644.49,
Simple pneumonia & pleurisy w CC,194,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6644.49,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6994.2,100,MS-DRG,5595.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6994.2,6644.49,
Simple pneumonia & pleurisy w/o CC/MCC,195,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5039.94,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5305.2,100,MS-DRG,4244.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5305.2,5039.94,
Interstitial lung disease w MCC,196,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6335.55,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6669,100,MS-DRG,5335.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6669,6335.55,
Interstitial lung disease w CC,197,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6335.55,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6669,100,MS-DRG,5335.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6669,6335.55,
Interstitial lung disease w/o CC/MCC,198,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4925.37,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5184.6,100,MS-DRG,4147.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5184.6,4925.37,
Pneumothorax w MCC,199,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7435.08,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7826.4,100,MS-DRG,6261.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7826.4,7435.08,
Pneumothorax w CC,200,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7435.08,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7826.4,100,MS-DRG,6261.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7826.4,7435.08,
Pneumothorax w/o CC/MCC,201,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5013.72,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5277.6,100,MS-DRG,4222.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5277.6,5013.72,
Bronchitis & asthma w CC/MCC,202,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4814.22,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5067.6,100,MS-DRG,4054.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5067.6,4814.22,
Bronchitis & asthma w/o CC/MCC,203,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4104.57,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4320.6,100,MS-DRG,3456.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4320.6,4104.57,
Respiratory signs & symptoms,204,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4601.04,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4843.2,100,MS-DRG,3874.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4843.2,4601.04,
Other respiratory system diagnoses w MCC,205,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4822.2,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5076,100,MS-DRG,4060.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5076,4822.2,
Other respiratory system diagnoses w/o MCC,206,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3899.37,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4104.6,100,MS-DRG,3283.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4104.6,3899.37,
Respiratory system diagnosis w ventilator support 96> hours,207,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18101.49,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19054.2,100,MS-DRG,15243.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19054.2,18101.49,
Respiratory system diagnosis w ventilator support <96 hours,208,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18101.49,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19054.2,100,MS-DRG,15243.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19054.2,18101.49,
Other heart assist system implant,215,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,66393.03,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,69887.4,100,MS-DRG,55909.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,69887.4,66393.03,
Cardiac valve & oth maj cardiothoracic proc w card cath w MCC,216,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,41696.07,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,43890.6,100,MS-DRG,35112.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43890.6,41696.07,
Cardiac valve & oth maj cardiothoracic proc w card cath w CC,217,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,41696.07,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,43890.6,100,MS-DRG,35112.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43890.6,41696.07,
Cardiac valve & oth maj cardiothoracic proc w card cath w/o CC/MCC,218,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,41696.07,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,43890.6,100,MS-DRG,35112.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,43890.6,41696.07,
Cardiac valve & oth maj cardiothoracic proc w/o card cath w MCC,219,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,36131.16,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,38032.8,100,MS-DRG,30426.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38032.8,36131.16,
Cardiac valve & oth maj cardiothoracic proc w/o card cath w CC,220,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,36131.16,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,38032.8,100,MS-DRG,30426.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38032.8,36131.16,
Cardiac valve & oth maj cardiothoracic proc w/o card cath w/o CC/MCC,221,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,36131.16,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,38032.8,100,MS-DRG,30426.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,38032.8,36131.16,
Cardiac defib implant w cardiac cath w AMI/HF/shock w MCC,222,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,46489.2,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,48936,100,MS-DRG,39148.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48936,46489.2,
Cardiac defib implant w cardiac cath w AMI/HF/shock w/o MCC,223,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,46489.2,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,48936,100,MS-DRG,39148.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,48936,46489.2,
Cardiac defib implant w cardiac cath w/o AMI/HF/shock w MCC,224,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,35781.75,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,37665,100,MS-DRG,30132,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37665,35781.75,
Cardiac defib implant w cardiac cath w/o AMI/HF/shock w/o MCC,225,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,35781.75,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,37665,100,MS-DRG,30132,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37665,35781.75,
Cardiac defibrillator implant w/o cardiac cath w MCC,226,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,28445.85,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,29943,100,MS-DRG,23954.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29943,28445.85,
Cardiac defibrillator implant w/o cardiac cath w/o MCC,227,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,28445.85,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,29943,100,MS-DRG,23954.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29943,28445.85,
Other cardiothoracic procedures w MCC,228,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,27247.71,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,28681.8,100,MS-DRG,22945.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28681.8,27247.71,
Other cardiothoracic procedures w/o MCC,229,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,27247.71,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,28681.8,100,MS-DRG,22945.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28681.8,27247.71,
Coronary bypass w PTCA w MCC,231,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,42003.3,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,44214,100,MS-DRG,35371.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44214,42003.3,
Coronary bypass w PTCA w/o MCC,232,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,42003.3,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,44214,100,MS-DRG,35371.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,44214,42003.3,
Coronary bypass w cardiac cath w MCC,233,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,35310.36,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,37168.8,100,MS-DRG,29735.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,37168.8,35310.36,
Coronary bypass w cardiac cath w/o MCC,234,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,26902.86,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,28318.8,100,MS-DRG,22655.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,28318.8,26902.86,
Coronary bypass w/o cardiac cath w MCC,235,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,29058.6,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,30588,100,MS-DRG,24470.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30588,29058.6,
Coronary bypass w/o cardiac cath w/o MCC,236,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,20606.07,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,21690.6,100,MS-DRG,17352.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21690.6,20606.07,
Amputation for circ sys disorders exc upper limb & toe w MCC,239,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14446.65,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,15207,100,MS-DRG,12165.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15207,14446.65,
Amputation for circ sys disorders exc upper limb & toe w CC,240,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14446.65,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,15207,100,MS-DRG,12165.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15207,14446.65,
Amputation for circ sys disorders exc upper limb & toe w/o CC/MCC,241,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14446.65,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,15207,100,MS-DRG,12165.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15207,14446.65,
Permanent cardiac pacemaker implant w MCC,242,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,17673.99,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,18604.2,100,MS-DRG,14883.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18604.2,17673.99,
Permanent cardiac pacemaker implant w CC,243,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,17673.99,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,18604.2,100,MS-DRG,14883.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18604.2,17673.99,
Permanent cardiac pacemaker implant w/o CC/MCC,244,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11967.72,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12597.6,100,MS-DRG,10078.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12597.6,11967.72,
AICD generator procedures,245,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,17673.99,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,18604.2,100,MS-DRG,14883.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18604.2,17673.99,
Percutaneous cardiovascular proc w drug-eluting stent w MCC or 4+ Arteries/Stents,246,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,16368.69,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,17230.2,100,MS-DRG,13784.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17230.2,16368.69,
Percutaneous cardiovascular proc w drug-eluting stent w/o MCC,247,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12601.56,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13264.8,100,MS-DRG,10611.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13264.8,12601.56,
Percutaneous cardiovasccular proc w non-drug-eluting stent w MCC or 4+ Arteries/Stents,248,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13859.55,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14589,100,MS-DRG,11671.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14589,13859.55,
Percutaneous cardiovascular proc w non-drug-eluting stent w/o MCC,249,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10905.24,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11479.2,100,MS-DRG,9183.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11479.2,10905.24,
Perc cardiovasc proc w/o coronary artery stent or AMI w MCC,250,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9683.73,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10193.4,100,MS-DRG,8154.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10193.4,9683.73,
Perc cardiovasc proc w/o coronary artery stent or AMI w/o MCC,251,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9683.73,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10193.4,100,MS-DRG,8154.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10193.4,9683.73,
Other vascular procedures w MCC,252,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,17645.49,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,18574.2,100,MS-DRG,14859.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18574.2,17645.49,
Other vascular procedures w CC,253,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,17645.49,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,18574.2,100,MS-DRG,14859.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18574.2,17645.49,
Other vascular procedures w/o CC/MCC,254,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11810.97,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12432.6,100,MS-DRG,9946.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12432.6,11810.97,
Upper limb & toe amputation for circ system disorders w MCC,255,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10783.26,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11350.8,100,MS-DRG,9080.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11350.8,10783.26,
Upper limb & toe amputation for circ system disorders w CC,256,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10783.26,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11350.8,100,MS-DRG,9080.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11350.8,10783.26,
Upper limb & toe amputation for circ system disorders w/o CC/MCC,257,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10783.26,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11350.8,100,MS-DRG,9080.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11350.8,10783.26,
Cardiac pacemaker device replacement w MCC,258,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10957.68,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11534.4,100,MS-DRG,9227.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11534.4,10957.68,
Cardiac pacemaker device replacement w/o MCC,259,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10957.68,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11534.4,100,MS-DRG,9227.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11534.4,10957.68,
Cardiac pacemaker revision except device replacement w MCC,260,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7403.73,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7793.4,100,MS-DRG,6234.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7793.4,7403.73,
Cardiac pacemaker revision except device replacement w CC,261,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7403.73,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7793.4,100,MS-DRG,6234.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7793.4,7403.73,
Cardiac pacemaker revision except device replacement w/o CC/MCC,262,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7403.73,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7793.4,100,MS-DRG,6234.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7793.4,7403.73,
Vein ligation & stripping,263,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5223.48,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5498.4,100,MS-DRG,4398.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5498.4,5223.48,
Other circulatory system O.R. procedures,264,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12868.89,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13546.2,100,MS-DRG,10836.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13546.2,12868.89,
AICD lead procedures,265,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,17673.99,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,18604.2,100,MS-DRG,14883.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18604.2,17673.99,
Endovascular Cardiac Valve Replacement & Supplement Procedures w MCC,266,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,51254.4,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,53952,100,MS-DRG,43161.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,53952,51254.4,
Endovascular Cardiac Valve Replacement & Supplement Procedures w/o MCC,267,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,38484.69,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,40510.2,100,MS-DRG,32408.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,40510.2,38484.69,
Aortic and Heart Assist Procedures Except Pulsation Balloon w/MCC,268,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18877.26,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19870.8,100,MS-DRG,15896.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19870.8,18877.26,
Aortic and Heart Assist Procedures Except Pulsation Balloon w/out MCC,269,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13992.93,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14729.4,100,MS-DRG,11783.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14729.4,13992.93,
Other Major Cardiovascular Procedures w/MCC,270,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18877.26,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19870.8,100,MS-DRG,15896.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19870.8,18877.26,
Other Major Cardiovascular Procedures w/CC,271,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18877.26,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19870.8,100,MS-DRG,15896.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19870.8,18877.26,
Other Major Cardiovascular Procedures w/out CC/MCC,272,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13992.93,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14729.4,100,MS-DRG,11783.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14729.4,13992.93,
Percutaneous Intracardiac Procedures w/MCC,273,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9683.73,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10193.4,100,MS-DRG,8154.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10193.4,9683.73,
Percutaneous Intracardiac Procedures w/out MCC,274,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9683.73,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10193.4,100,MS-DRG,8154.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10193.4,9683.73,
"Acute myocardial infarction, discharged alive w MCC",280,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10081.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10612.2,100,MS-DRG,8489.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10612.2,10081.59,
"Acute myocardial infarction, discharged alive w CC",281,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10081.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10612.2,100,MS-DRG,8489.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10612.2,10081.59,
"Acute myocardia infarction, discharged alive w/o CC/MCC",282,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7562.19,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7960.2,100,MS-DRG,6368.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7960.2,7562.19,
"Acute myocardial infarction, expired w MCC",283,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7811.28,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8222.4,100,MS-DRG,6577.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8222.4,7811.28,
"Acute myocardial infarction, expired w CC",284,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7811.28,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8222.4,100,MS-DRG,6577.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8222.4,7811.28,
"Acute myocardial infarction, expired w/o CC/MCC",285,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7811.28,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8222.4,100,MS-DRG,6577.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8222.4,7811.28,
"Circulatory disorders except AMI, w card cath w MCC",286,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7154.07,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7530.6,100,MS-DRG,6024.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7530.6,7154.07,
"Circulatory disorders except AMI, w card cath w/o MCC",287,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4141.05,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4359,100,MS-DRG,3487.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4359,4141.05,
Acute & subacute endocarditis w MCC,288,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,17006.52,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,17901.6,100,MS-DRG,14321.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17901.6,17006.52,
Acute & subacute endocarditis w CC,289,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,17006.52,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,17901.6,100,MS-DRG,14321.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17901.6,17006.52,
Acute & subacute endocarditis w/o CC/MCC,290,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,17006.52,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,17901.6,100,MS-DRG,14321.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17901.6,17006.52,
Heart failure & shock w MCC,291,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5755.86,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6058.8,100,MS-DRG,4847.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6058.8,5755.86,
Heart failure & shock w CC,292,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5755.86,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6058.8,100,MS-DRG,4847.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6058.8,5755.86,
Heart failure & shock w/o CC/MCC,293,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5755.86,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6058.8,100,MS-DRG,4847.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6058.8,5755.86,
Deep vein thrombophlebitis w CC/MCC,294,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4819.92,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5073.6,100,MS-DRG,4058.88,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5073.6,4819.92,
Deep vein thrombophlebitis w/o CC/MCC,295,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4819.92,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5073.6,100,MS-DRG,4058.88,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5073.6,4819.92,
"Cardiac arrest, unexplained w MCC",296,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9803.43,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10319.4,100,MS-DRG,8255.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10319.4,9803.43,
"Cardiac arrest, unexplained w CC",297,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9803.43,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10319.4,100,MS-DRG,8255.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10319.4,9803.43,
"Cardiac arrest, unexplained w/o CC/MCC",298,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9803.43,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10319.4,100,MS-DRG,8255.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10319.4,9803.43,
Peripheral vascular disorders w MCC,299,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4703.07,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4950.6,100,MS-DRG,3960.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4950.6,4703.07,
Peripheral vascular disorders w CC,300,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4703.07,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4950.6,100,MS-DRG,3960.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4950.6,4703.07,
Peripheral vascular disorders w/o CC/MCC,301,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3821.85,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4023,100,MS-DRG,3218.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4023,3821.85,
Atherosclerosis w MCC,302,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4581.09,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4822.2,100,MS-DRG,3857.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4822.2,4581.09,
Atherosclerosis w/o MCC,303,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4017.93,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4229.4,100,MS-DRG,3383.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4229.4,4017.93,
Hypertension w MCC,304,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3626.91,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3817.8,100,MS-DRG,3054.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3817.8,3626.91,
Hypertension w/o MCC,305,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3626.91,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3817.8,100,MS-DRG,3054.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3817.8,3626.91,
Cardiac congenital & valvular disorders w MCC,306,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5094.09,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5362.2,100,MS-DRG,4289.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5362.2,5094.09,
Cardiac congenital & valvular disorders w/o MCC,307,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4289.25,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4515,100,MS-DRG,3612,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4515,4289.25,
Cardiac arrhythmia & conduction disorders w MCC,308,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4637.52,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4881.6,100,MS-DRG,3905.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4881.6,4637.52,
Cardiac arrhythmia & conduction disorders w CC,309,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4637.52,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4881.6,100,MS-DRG,3905.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4881.6,4637.52,
Cardiac arrhythmia & conduction disorders w/o CC/MCC,310,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3712.98,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3908.4,100,MS-DRG,3126.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3908.4,3712.98,
Angina pectoris,311,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3929.58,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4136.4,100,MS-DRG,3309.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4136.4,3929.58,
Syncope & collapse,312,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3526.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3712.2,100,MS-DRG,2969.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3712.2,3526.59,
Chest pain,313,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3359.01,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3535.8,100,MS-DRG,2828.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3535.8,3359.01,
Other circulatory system diagnoses w MCC,314,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6361.2,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6696,100,MS-DRG,5356.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6696,6361.2,
Other circulatory system diagnoses w CC,315,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6361.2,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6696,100,MS-DRG,5356.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6696,6361.2,
Other circulatory system diagnoses w/o CC/MCC,316,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4830.75,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5085,100,MS-DRG,4068,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5085,4830.75,
Other Endovascular Cardiac Valve Procedures w MCC,319,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9683.73,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10193.4,100,MS-DRG,8154.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10193.4,9683.73,
Other Endovascular Cardic Valve Procedures w/o MCC,320,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9683.73,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10193.4,100,MS-DRG,8154.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10193.4,9683.73,
"Stomach, esophageal & duodenal proc w MCC",326,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,15319.32,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16125.6,100,MS-DRG,12900.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16125.6,15319.32,
"Stomach, esophageal & duodenal proc w CC",327,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,15319.32,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16125.6,100,MS-DRG,12900.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16125.6,15319.32,
"Stomach, esophageal & duodenal proc w/o CC/MCC",328,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10204.14,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10741.2,100,MS-DRG,8592.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10741.2,10204.14,
Major small & large bowel procedures w MCC,329,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,16758.57,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,17640.6,100,MS-DRG,14112.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17640.6,16758.57,
Major small & large bowel procedures w CC,330,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,16758.57,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,17640.6,100,MS-DRG,14112.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,17640.6,16758.57,
Major small & large bowel procedures w/o CC/MCC,331,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12009.33,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12641.4,100,MS-DRG,10113.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12641.4,12009.33,
Rectal resection w MCC,332,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,17528.07,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,18450.6,100,MS-DRG,14760.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18450.6,17528.07,
Rectal resection w CC,333,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,17528.07,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,18450.6,100,MS-DRG,14760.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18450.6,17528.07,
Rectal resection w/o CC/MCC,334,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12958.95,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13641,100,MS-DRG,10912.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13641,12958.95,
Peritoneal adhesiolysis w MCC,335,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13352.82,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14055.6,100,MS-DRG,11244.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14055.6,13352.82,
Peritoneal adhesiolysis w CC,336,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13352.82,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14055.6,100,MS-DRG,11244.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14055.6,13352.82,
Peritoneal adhesiolysis w/o CC/MCC,337,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9063,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9540,100,MS-DRG,7632,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9540,9063,
Appendectomy w complicated principal diag w MCC,338,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11768.22,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12387.6,100,MS-DRG,9910.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12387.6,11768.22,
Appendectomy w complicated principal diag w CC,339,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11768.22,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12387.6,100,MS-DRG,9910.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12387.6,11768.22,
Appendectomy w complicated principal diag w/o CC/MCC,340,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8193.75,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8625,100,MS-DRG,6900,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8625,8193.75,
Appendectomy w/o complicated principal diag w MCC,341,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7754.28,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8162.4,100,MS-DRG,6529.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8162.4,7754.28,
Appendectomy w/o complicated principal diag w CC,342,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7754.28,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8162.4,100,MS-DRG,6529.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8162.4,7754.28,
Appendectomy w/o complicated principal diag w/o CC/MCC,343,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5057.04,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5323.2,100,MS-DRG,4258.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5323.2,5057.04,
Minor small & large bowel procedures w MCC,344,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8013.63,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8435.4,100,MS-DRG,6748.32,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8435.4,8013.63,
Minor small & large bowel procedures w CC,345,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8013.63,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8435.4,100,MS-DRG,6748.32,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8435.4,8013.63,
Minor small & large bowel procedures w/o CC/MCC,346,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6265.44,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6595.2,100,MS-DRG,5276.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6595.2,6265.44,
Anal & stomal procedures w MCC,347,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4162.14,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4381.2,100,MS-DRG,3504.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4381.2,4162.14,
Anal & stomal procedures w CC,348,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4162.14,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4381.2,100,MS-DRG,3504.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4381.2,4162.14,
Anal & stomal procedures w/o CC/MCC,349,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3141.27,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3306.6,100,MS-DRG,2645.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3306.6,3141.27,
Inguinal & femoral hernia procedures w MCC,350,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5498.79,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5788.2,100,MS-DRG,4630.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5788.2,5498.79,
Inguinal & femoral hernia procedures w CC,351,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5498.79,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5788.2,100,MS-DRG,4630.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5788.2,5498.79,
Inguinal & femoral hernia procedures w/o CC/MCC,352,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3725.52,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3921.6,100,MS-DRG,3137.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3921.6,3725.52,
Hernia procedures except inguinal & femoral w MCC,353,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5698.29,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5998.2,100,MS-DRG,4798.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5998.2,5698.29,
Hernia procedures except inguinal & femoral w CC,354,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5698.29,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5998.2,100,MS-DRG,4798.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5998.2,5698.29,
Hernia procedures except inguinal & femoral w/o CC/MCC,355,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4250.49,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4474.2,100,MS-DRG,3579.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4474.2,4250.49,
Other digestive system O.R. procedures w MCC,356,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,15738.27,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16566.6,100,MS-DRG,13253.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16566.6,15738.27,
Other digestive system O.R. procedures w CC,357,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,15738.27,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16566.6,100,MS-DRG,13253.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16566.6,15738.27,
Other digestive system O.R. procedures w/o CC/MCC,358,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13278.15,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13977,100,MS-DRG,11181.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13977,13278.15,
Major esophageal disorders w MCC,368,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6341.82,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6675.6,100,MS-DRG,5340.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6675.6,6341.82,
Major esophageal disorders w CC,369,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6341.82,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6675.6,100,MS-DRG,5340.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6675.6,6341.82,
Major esophageal disorders w/o CC/MCC,370,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6341.82,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6675.6,100,MS-DRG,5340.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6675.6,6341.82,
Major gastrointestinal disorders & peritoneal infections w MCC,371,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7625.46,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8026.8,100,MS-DRG,6421.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8026.8,7625.46,
Major gastrointestinal disorders & peritoneal infections w CC,372,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7625.46,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8026.8,100,MS-DRG,6421.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8026.8,7625.46,
Major gastrointestinal disorders & peritoneal infections w/o CC/MCC,373,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7625.46,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8026.8,100,MS-DRG,6421.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8026.8,7625.46,
Digestive malignancy w MCC,374,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6126.36,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6448.8,100,MS-DRG,5159.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6448.8,6126.36,
Digestive malignancy w CC,375,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6126.36,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6448.8,100,MS-DRG,5159.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6448.8,6126.36,
Digestive malignancy w/o CC/MCC,376,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5473.14,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5761.2,100,MS-DRG,4608.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5761.2,5473.14,
G.I. hemorrhage w MCC,377,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5171.61,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5443.8,100,MS-DRG,4355.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5443.8,5171.61,
G.I. hemorrhage w CC,378,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5171.61,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5443.8,100,MS-DRG,4355.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5443.8,5171.61,
G.I. hemorrhage w/o CC/MCC,379,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4028.19,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4240.2,100,MS-DRG,3392.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4240.2,4028.19,
Complicated peptic ulcer w MCC,380,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5310.12,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5589.6,100,MS-DRG,4471.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5589.6,5310.12,
Complicated peptic ulcer w CC,381,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5310.12,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5589.6,100,MS-DRG,4471.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5589.6,5310.12,
Complicated peptic ulcer w/o CC/MCC,382,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5310.12,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5589.6,100,MS-DRG,4471.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5589.6,5310.12,
Uncomplicated peptic ulcer w MCC,383,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3770.55,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3969,100,MS-DRG,3175.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3969,3770.55,
Uncomplicated peptic ulcer w/o MCC,384,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3165.78,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3332.4,100,MS-DRG,2665.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3332.4,3165.78,
Inflammatory bowel disease w MCC,385,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5628.75,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5925,100,MS-DRG,4740,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5925,5628.75,
Inflammatory bowel disease w CC,386,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5628.75,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5925,100,MS-DRG,4740,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5925,5628.75,
Inflammatory bowel disease w/o CC/MCC,387,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5628.75,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5925,100,MS-DRG,4740,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5925,5628.75,
G.I. obstruction w MCC,388,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4322.31,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4549.8,100,MS-DRG,3639.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4549.8,4322.31,
G.I. obstruction w CC,389,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4322.31,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4549.8,100,MS-DRG,3639.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4549.8,4322.31,
G.I. obstruction w/o CC/MCC,390,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3321.39,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3496.2,100,MS-DRG,2796.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3496.2,3321.39,
"Esophagitis, gastroent & misc digest disorders w MCC",391,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3438.24,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3619.2,100,MS-DRG,2895.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3619.2,3438.24,
"Esophagitis, gastroent & misc digest disorders w/o MCC",392,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2909.28,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3062.4,100,MS-DRG,2449.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3062.4,2909.28,
Other digestive system diagnoses w MCC,393,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5231.46,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5506.8,100,MS-DRG,4405.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5506.8,5231.46,
Other digestive system diagnoses w CC,394,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5231.46,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5506.8,100,MS-DRG,4405.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5506.8,5231.46,
Other digestive system diagnoses w/o CC/MCC,395,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4087.47,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4302.6,100,MS-DRG,3442.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4302.6,4087.47,
"Pancreas, liver & shunt procedures w MCC",405,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,25423.71,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,26761.8,100,MS-DRG,21409.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26761.8,25423.71,
"Pancreas, liver & shunt procedures w CC",406,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,25423.71,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,26761.8,100,MS-DRG,21409.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,26761.8,25423.71,
"Pancreas, liver & shunt procedures w/o CC/MCC",407,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,23049.09,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,24262.2,100,MS-DRG,19409.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,24262.2,23049.09,
Biliary tract proc except only cholecyst w or w/o c.d.e. w MCC,408,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,16025.55,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16869,100,MS-DRG,13495.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16869,16025.55,
Biliary tract proc except only cholecyst w or w/o c.d.e. w CC,409,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,16025.55,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16869,100,MS-DRG,13495.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16869,16025.55,
Biliary tract proc except only cholecyst w or w/o c.d.e. w/o CC/MCC,410,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12086.28,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12722.4,100,MS-DRG,10177.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12722.4,12086.28,
Cholecystectomy w c.d.e. w MCC,411,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12952.68,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13634.4,100,MS-DRG,10907.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13634.4,12952.68,
Cholecystectomy w c.d.e. w CC,412,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12952.68,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13634.4,100,MS-DRG,10907.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13634.4,12952.68,
Cholecystectomy w c.d.e. w/o CC/MCC,413,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9105.18,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9584.4,100,MS-DRG,7667.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9584.4,9105.18,
Cholecystectomy except by laparoscope w/o c.d.e. w MCC,414,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9721.35,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10233,100,MS-DRG,8186.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10233,9721.35,
Cholecystectomy except by laparoscope w/o c.d.e. w CC,415,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9721.35,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10233,100,MS-DRG,8186.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10233,9721.35,
Cholecystectomy except by laparoscope w/o c.d.e. w/o CC/MCC,416,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6497.43,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6839.4,100,MS-DRG,5471.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6839.4,6497.43,
Laparoscopic cholecystectomy w/o c.d.e. w MCC,417,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8702.76,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9160.8,100,MS-DRG,7328.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9160.8,8702.76,
Laparoscopic cholecystectomy w/o c.d.e. w CC,418,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8702.76,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9160.8,100,MS-DRG,7328.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9160.8,8702.76,
Laparoscopic cholecystectomy w/o c.d.e. w/o CC/MCC,419,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4692.81,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4939.8,100,MS-DRG,3951.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4939.8,4692.81,
Hepatobiliary diagnostic procedures w MCC,420,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14980.17,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,15768.6,100,MS-DRG,12614.88,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15768.6,14980.17,
Hepatobiliary diagnostic procedures w CC,421,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14980.17,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,15768.6,100,MS-DRG,12614.88,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15768.6,14980.17,
Hepatobiliary diagnostic procedures w/o CC/MCC,422,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13326.03,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14027.4,100,MS-DRG,11221.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14027.4,13326.03,
Other hepatobiliary or pancreas O.R. procedures w MCC,423,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,15461.25,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16275,100,MS-DRG,13020,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16275,15461.25,
Other hepatobiliary or pancreas O.R. procedures w CC,424,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,15461.25,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16275,100,MS-DRG,13020,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16275,15461.25,
Other hepatobiliary or pancreas O.R. procedures w/o CC/MCC,425,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,15461.25,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16275,100,MS-DRG,13020,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16275,15461.25,
Cirrhosis & alcoholic hepatitis w MCC,432,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6649.05,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6999,100,MS-DRG,5599.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6999,6649.05,
Cirrhosis & alcoholic hepatitis w CC,433,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6649.05,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6999,100,MS-DRG,5599.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6999,6649.05,
Cirrhosis & alcoholic hepatitis w/o CC/MCC,434,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6649.05,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6999,100,MS-DRG,5599.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6999,6649.05,
Malignancy of hepatobiliary system or pancreas w MCC,435,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5892.66,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6202.8,100,MS-DRG,4962.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6202.8,5892.66,
Malignancy of hepatobiliary system or pancreas w CC,436,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5892.66,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6202.8,100,MS-DRG,4962.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6202.8,5892.66,
Malignancy of hepatobiliary system or pancreas w/o CC/MCC,437,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5892.66,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6202.8,100,MS-DRG,4962.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6202.8,5892.66,
Disorders of pancreas except malignancy w MCC,438,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5527.86,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5818.8,100,MS-DRG,4655.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5818.8,5527.86,
Disorders of pancreas except malignancy w CC,439,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5527.86,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5818.8,100,MS-DRG,4655.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5818.8,5527.86,
Disorders of pancreas except malignancy w/o CC/MCC,440,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5527.86,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5818.8,100,MS-DRG,4655.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5818.8,5527.86,
"Disorders of liver except malig,cirr,alc hepa w MCC",441,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6109.26,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6430.8,100,MS-DRG,5144.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6430.8,6109.26,
"Disorders of liver except malig,cirr,alc hepa w CC",442,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6109.26,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6430.8,100,MS-DRG,5144.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6430.8,6109.26,
"Disorders of liver except malig,cirr,alc hepa w/o CC/MCC",443,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4408.95,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4641,100,MS-DRG,3712.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4641,4408.95,
Disorders of the biliary tract w MCC,444,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4431.75,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4665,100,MS-DRG,3732,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4665,4431.75,
Disorders of the biliary tract w CC,445,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4431.75,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4665,100,MS-DRG,3732,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4665,4431.75,
Disorders of the biliary tract w/o CC/MCC,446,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3302.01,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3475.8,100,MS-DRG,2780.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3475.8,3302.01,
Combined anterior/posterior spinal fusion w MCC,453,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,31471.98,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,33128.4,100,MS-DRG,26502.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33128.4,31471.98,
Combined anterior/posterior spinal fusion w CC,454,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,31471.98,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,33128.4,100,MS-DRG,26502.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33128.4,31471.98,
Combined anterior/posterior spinal fusion w/o CC/MCC,455,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,31471.98,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,33128.4,100,MS-DRG,26502.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33128.4,31471.98,
Spinal fusion exc cerv w spinal curv/malig/infec or ext fus w MCC,456,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,28921.23,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,30443.4,100,MS-DRG,24354.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30443.4,28921.23,
Spinal fusion exc cerv w spinal curv/malig/infec or ext fus w CC,457,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,28921.23,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,30443.4,100,MS-DRG,24354.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30443.4,28921.23,
Spinal fusion exc cerv w spinal curv/malig/infec or ext fus w/out CC/MCC,458,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,28921.23,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,30443.4,100,MS-DRG,24354.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,30443.4,28921.23,
Spinal fusion except cervical w MCC,459,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,15784.44,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16615.2,100,MS-DRG,13292.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16615.2,15784.44,
Spinal fusion except cervical w/o MCC,460,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9217.47,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9702.6,100,MS-DRG,7762.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9702.6,9217.47,
Bilateral or multiple major joint procs of lower extremity w MCC,461,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,21084.87,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,22194.6,100,MS-DRG,17755.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22194.6,21084.87,
Bilateral or multiple major joint procs of lower extremity w/o MCC,462,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,21084.87,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,22194.6,100,MS-DRG,17755.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,22194.6,21084.87,
"Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w MCC",463,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13165.29,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13858.2,100,MS-DRG,11086.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13858.2,13165.29,
"Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w CC",464,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13165.29,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13858.2,100,MS-DRG,11086.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13858.2,13165.29,
"Wnd debrid & skn grft exc hand, for musculo-conn tiss dis w/o CC/MCC",465,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13165.29,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13858.2,100,MS-DRG,11086.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13858.2,13165.29,
Revision of hip or knee replacement w MCC,466,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14151.39,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14896.2,100,MS-DRG,11916.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14896.2,14151.39,
Revision of hip or knee replacement w CC,467,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14151.39,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14896.2,100,MS-DRG,11916.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14896.2,14151.39,
Revision of hip or knee replacement w/o CC/MCC,468,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14151.39,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14896.2,100,MS-DRG,11916.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14896.2,14151.39,
Major hip and knee joint replacement or reattachment of lower extremity w MCC or total ankle replacement,469,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11196.51,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11785.8,100,MS-DRG,9428.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11785.8,11196.51,
Major hip and knee joint replacement or reattachment of lower extremity w/o MCC ,470,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11196.51,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11785.8,100,MS-DRG,9428.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11785.8,11196.51,
Cervical spinal fusion w MCC,471,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13251.93,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13949.4,100,MS-DRG,11159.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13949.4,13251.93,
Cervical spinal fusion w CC,472,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13251.93,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13949.4,100,MS-DRG,11159.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13949.4,13251.93,
Cervical spinal fusion w/o CC/MCC,473,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8091.15,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8517,100,MS-DRG,6813.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8517,8091.15,
Amputation for musculoskeletal sys & conn tissue dis w MCC,474,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11257.5,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11850,100,MS-DRG,9480,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11850,11257.5,
Amputation for musculoskeletal sys & conn tissue dis w CC,475,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11257.5,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11850,100,MS-DRG,9480,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11850,11257.5,
Amputation for musculoskeletal sys & conn tissue dis w/o CC/MCC,476,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11257.5,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11850,100,MS-DRG,9480,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11850,11257.5,
Biopsies of musculoskeletal system & connective tissue w MCC,477,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8872.05,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9339,100,MS-DRG,7471.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9339,8872.05,
Biopsies of musculoskeletal system & connective tissue w CC,478,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8872.05,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9339,100,MS-DRG,7471.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9339,8872.05,
Biopsies of musculoskeletal system & connective tissue w/o CC/MCC,479,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8872.05,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9339,100,MS-DRG,7471.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9339,8872.05,
Hip & femur procedures except major joint w MCC,480,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11580.69,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12190.2,100,MS-DRG,9752.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12190.2,11580.69,
Hip & femur procedures except major joint w CC,481,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11580.69,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12190.2,100,MS-DRG,9752.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12190.2,11580.69,
Hip & femur procedures except major joint w/o CC/MCC,482,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10183.62,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10719.6,100,MS-DRG,8575.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10719.6,10183.62,
Major joint & limb reattachment proc of upper extremities,483,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8910.24,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9379.2,100,MS-DRG,7503.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9379.2,8910.24,
Knee procedures w pdx of infection w MCC,485,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14626.2,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,15396,100,MS-DRG,12316.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15396,14626.2,
Knee procedures w pdx of infection w CC,486,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14626.2,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,15396,100,MS-DRG,12316.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15396,14626.2,
Knee procedures w pdx of infection w/o CC/MCC,487,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9122.28,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9602.4,100,MS-DRG,7681.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9602.4,9122.28,
Knee procedures w/o pdx of infection w CC/MCC,488,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7056.6,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7428,100,MS-DRG,5942.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7428,7056.6,
Knee procedures w/o pdx of infection w/o CC/MCC,489,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7056.6,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7428,100,MS-DRG,5942.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7428,7056.6,
"Lower extrem & humer proc except hip,foot,femur w MCC",492,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7864.29,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8278.2,100,MS-DRG,6622.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8278.2,7864.29,
"Lower extrem & humer proc except hip,foot,femur w CC",493,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7864.29,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8278.2,100,MS-DRG,6622.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8278.2,7864.29,
"Lower extrem & humer proc except hip,foot,femur w/o CC/MCC",494,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5948.52,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6261.6,100,MS-DRG,5009.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6261.6,5948.52,
Local excision & removal int fix devices exc hip & femur w MCC,495,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10365.45,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10911,100,MS-DRG,8728.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10911,10365.45,
Local excision & removal int fix devices exc hip & femur w CC,496,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10365.45,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10911,100,MS-DRG,8728.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10911,10365.45,
Local excision & removal int fix devices exc hip & femur w/o CC/MCC,497,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5653.83,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5951.4,100,MS-DRG,4761.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5951.4,5653.83,
Local excision & removal int fix devices of hip & femur w CC/MCC,498,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5788.92,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6093.6,100,MS-DRG,4874.88,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6093.6,5788.92,
Local excision & removal int fix devices of hip & femur w/o CC/MCC,499,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5788.92,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6093.6,100,MS-DRG,4874.88,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6093.6,5788.92,
Soft tissue procedures w MCC,500,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5006.31,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5269.8,100,MS-DRG,4215.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5269.8,5006.31,
Soft tissue procedures w CC,501,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5006.31,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5269.8,100,MS-DRG,4215.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5269.8,5006.31,
Soft tissue procedures w/o CC/MCC,502,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3746.61,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3943.8,100,MS-DRG,3155.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3943.8,3746.61,
Foot procedures w MCC,503,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3734.64,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3931.2,100,MS-DRG,3144.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3931.2,3734.64,
Foot procedures w CC,504,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3734.64,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3931.2,100,MS-DRG,3144.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3931.2,3734.64,
Foot procedures w/o CC/MCC,505,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3734.64,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3931.2,100,MS-DRG,3144.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3931.2,3734.64,
Major thumb or joint procedures,506,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4662.6,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4908,100,MS-DRG,3926.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4908,4662.6,
Major shoulder or elbow joint procedures w CC/MCC,507,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6989.91,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7357.8,100,MS-DRG,5886.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7357.8,6989.91,
Major shoulder or elbow joint procedures w/o CC/MCC,508,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6989.91,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7357.8,100,MS-DRG,5886.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7357.8,6989.91,
Arthroscopy,509,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3832.11,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4033.8,100,MS-DRG,3227.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4033.8,3832.11,
"Shoulder,elbow or forearm proc,exc major joint proc w MCC",510,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3929.58,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4136.4,100,MS-DRG,3309.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4136.4,3929.58,
"Shoulder,elbow or forearm proc,exc major joint proc w CC",511,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3929.58,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4136.4,100,MS-DRG,3309.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4136.4,3929.58,
"Shoulder,elbow or forearm proc,exc major joint proc w/o CC/MCC",512,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3929.58,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4136.4,100,MS-DRG,3309.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4136.4,3929.58,
"Hand or wrist proc, except major thumb or joint proc w CC/MCC",513,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2847.15,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2997,100,MS-DRG,2397.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2997,2847.15,
"Hand or wrist proc, except major thumb or joint proc w/o CC/MCC",514,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2847.15,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2997,100,MS-DRG,2397.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2997,2847.15,
Other musculoskelet sys & conn tiss O.R. proc w MCC,515,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7918.44,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8335.2,100,MS-DRG,6668.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8335.2,7918.44,
Other musculoskelet sys & conn tiss O.R. proc w CC,516,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7918.44,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8335.2,100,MS-DRG,6668.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8335.2,7918.44,
Other musculoskelet sys & conn tiss O.R. proc w/o CC/MCC,517,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5424.69,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5710.2,100,MS-DRG,4568.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5710.2,5424.69,
Back & Neck Procedures Except Spinal Fusion w MCC or Disc Device/Neurostimulator,518,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,17457.96,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,18376.8,100,MS-DRG,14701.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,18376.8,17457.96,
Back & Neck Procedures Except Spinal Fusion w CC,519,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9386.76,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9880.8,100,MS-DRG,7904.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9880.8,9386.76,
Back & Neck Procedures Except Spinal Fusion w/o CC/MCC,520,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6495.72,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6837.6,100,MS-DRG,5470.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6837.6,6495.72,
Fractures of femur w MCC,533,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8057.52,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8481.6,100,MS-DRG,6785.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8481.6,8057.52,
Fractures of femur w/o MCC,534,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8057.52,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8481.6,100,MS-DRG,6785.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8481.6,8057.52,
Fractures of hip & pelvis w MCC,535,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6105.84,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6427.2,100,MS-DRG,5141.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6427.2,6105.84,
Fractures of hip & pelvis w/o MCC,536,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6105.84,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6427.2,100,MS-DRG,5141.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6427.2,6105.84,
"Sprains, strains, & dislocations of hip, pelvis & thigh w CC/MCC",537,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3447.93,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3629.4,100,MS-DRG,2903.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3629.4,3447.93,
"Sprains, strains, & dislocations of hip, pelvis & thigh w/o CC/MCC",538,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3447.93,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3629.4,100,MS-DRG,2903.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3629.4,3447.93,
Osteomyelitis w MCC,539,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9388.47,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9882.6,100,MS-DRG,7906.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9882.6,9388.47,
Osteomyelitis w CC,540,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9388.47,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9882.6,100,MS-DRG,7906.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9882.6,9388.47,
Osteomyelitis w/o CC/MCC,541,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9388.47,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9882.6,100,MS-DRG,7906.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9882.6,9388.47,
Pathological fractures & musculoskelet & conn tiss malig w MCC,542,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5282.76,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5560.8,100,MS-DRG,4448.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5560.8,5282.76,
Pathological fractures & musculoskelet & conn tiss malig w CC,543,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5282.76,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5560.8,100,MS-DRG,4448.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5560.8,5282.76,
Pathological fractures & musculoskelet & conn tiss malig w/o CC/MCC,544,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5282.76,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5560.8,100,MS-DRG,4448.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5560.8,5282.76,
Connective tissue disorders w MCC,545,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5156.79,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5428.2,100,MS-DRG,4342.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5428.2,5156.79,
Connective tissue disorders w CC,546,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5156.79,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5428.2,100,MS-DRG,4342.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5428.2,5156.79,
Connective tissue disorders w/o CC/MCC,547,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4253.91,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4477.8,100,MS-DRG,3582.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4477.8,4253.91,
Septic arthritis w MCC,548,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8300.34,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8737.2,100,MS-DRG,6989.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8737.2,8300.34,
Septic arthritis w CC,549,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8300.34,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8737.2,100,MS-DRG,6989.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8737.2,8300.34,
Septic arthritis w/o CC/MCC,550,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8300.34,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8737.2,100,MS-DRG,6989.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8737.2,8300.34,
Medical back problems w MCC,551,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3898.8,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4104,100,MS-DRG,3283.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4104,3898.8,
Medical back problems w/o MCC,552,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3898.8,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4104,100,MS-DRG,3283.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4104,3898.8,
Bone diseases & arthropathies w MCC,553,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3842.94,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4045.2,100,MS-DRG,3236.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4045.2,3842.94,
Bone diseases & arthropathies w/o MCC,554,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3648,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3840,100,MS-DRG,3072,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3840,3648,
Signs & symptoms of musculoskeletal system & conn tissue w MCC,555,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3302.01,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3475.8,100,MS-DRG,2780.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3475.8,3302.01,
Signs & symptoms of musculoskeletal system & conn tissue w/o MCC,556,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3302.01,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3475.8,100,MS-DRG,2780.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3475.8,3302.01,
"Tendonitis, myositis & bursitis w MCC",557,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3358.44,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3535.2,100,MS-DRG,2828.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3535.2,3358.44,
"Tendonitis, myositis & bursitis w/o MCC",558,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3358.44,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3535.2,100,MS-DRG,2828.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3535.2,3358.44,
"Aftercare, musculoskeletal system & connective tissue w MCC",559,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4488.75,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4725,100,MS-DRG,3780,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,4488.75,
"Aftercare, musculoskeletal system & connective tissue w CC",560,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4488.75,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4725,100,MS-DRG,3780,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,4488.75,
"Aftercare, musculoskeletal system & connective tissue w/o CC/MCC",561,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4488.75,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4725,100,MS-DRG,3780,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4725,4488.75,
"Fx, sprn, strn & disl except femur, hip, pelvis & thigh w MCC",562,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3602.97,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3792.6,100,MS-DRG,3034.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3792.6,3602.97,
"Fx, sprn, strn & disl except femur, hip, pelvis & thigh w/o MCC",563,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2940.06,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3094.8,100,MS-DRG,2475.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3094.8,2940.06,
Other musculoskeletal sys & connective tissue diagnoses w MCC,564,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3984.87,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4194.6,100,MS-DRG,3355.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4194.6,3984.87,
Other musculoskeletal sys & connective tissue diagnoses w CC,565,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3984.87,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4194.6,100,MS-DRG,3355.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4194.6,3984.87,
Other musculoskeletal sys & connective tissue diagnoses w/o CC/MCC,566,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3984.87,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4194.6,100,MS-DRG,3355.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4194.6,3984.87,
Skin Debridement with MCC,570,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13778.61,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14503.8,100,MS-DRG,11603.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14503.8,13778.61,
Skin Debridement with CC,571,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13778.61,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14503.8,100,MS-DRG,11603.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14503.8,13778.61,
Skin Debridement w/o CC/MCC,572,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12424.86,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13078.8,100,MS-DRG,10463.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13078.8,12424.86,
Skin graft for skn ulcer or cellulitis w MCC,573,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13778.61,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14503.8,100,MS-DRG,11603.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14503.8,13778.61,
Skin graft for skn ulcer or cellulitis w CC,574,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13778.61,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14503.8,100,MS-DRG,11603.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14503.8,13778.61,
Skin graft for skn ulcer or cellulitis w/o CC/MCC,575,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12424.86,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13078.8,100,MS-DRG,10463.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13078.8,12424.86,
Skin graft exc for skin ulcer or cellulitis w MCC,576,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7961.19,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8380.2,100,MS-DRG,6704.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8380.2,7961.19,
Skin graft exc for skin ulcer or cellulitis w CC,577,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7961.19,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8380.2,100,MS-DRG,6704.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8380.2,7961.19,
Skin graft exc for skin ulcer or cellulitis w/o CC/MCC,578,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4168.41,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4387.8,100,MS-DRG,3510.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4387.8,4168.41,
"Other skin, subcut tiss & breast proc w MCC",579,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6460.38,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6800.4,100,MS-DRG,5440.32,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6800.4,6460.38,
"Other skin, subcut tiss & breast proc w CC",580,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6460.38,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6800.4,100,MS-DRG,5440.32,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6800.4,6460.38,
"Other skin, subcut tiss & breast proc w/o CC/MCC",581,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4344.54,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4573.2,100,MS-DRG,3658.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4573.2,4344.54,
Mastectomy for malignancy w CC/MCC,582,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6059.1,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6378,100,MS-DRG,5102.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6378,6059.1,
Mastectomy for malignancy w/o CC/MCC,583,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5526.72,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5817.6,100,MS-DRG,4654.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5817.6,5526.72,
"Breast biopsy, local excision & other breast procedures w CC/MCC",584,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4904.85,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5163,100,MS-DRG,4130.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5163,4904.85,
"Breast biopsy, local excision & other breast procedures w/o CC/MCC",585,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3795.63,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3995.4,100,MS-DRG,3196.32,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3995.4,3795.63,
Skin ulcers w MCC,592,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7188.84,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7567.2,100,MS-DRG,6053.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7567.2,7188.84,
Skin ulcers w CC,593,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7188.84,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7567.2,100,MS-DRG,6053.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7567.2,7188.84,
Skin ulcers w/o CC/MCC,594,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7188.84,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7567.2,100,MS-DRG,6053.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7567.2,7188.84,
Major skin disorders w MCC,595,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4858.68,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5114.4,100,MS-DRG,4091.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5114.4,4858.68,
Major skin disorders w/o MCC,596,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4543.47,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4782.6,100,MS-DRG,3826.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4782.6,4543.47,
Malignant breast disorders w MCC,597,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5909.19,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6220.2,100,MS-DRG,4976.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6220.2,5909.19,
Malignant breast disorders w CC,598,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5909.19,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6220.2,100,MS-DRG,4976.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6220.2,5909.19,
Malignant breast disorders w/o CC/MCC,599,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5631.6,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5928,100,MS-DRG,4742.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5928,5631.6,
Non-malignant breast disorders w CC/MCC,600,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3235.89,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3406.2,100,MS-DRG,2724.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3406.2,3235.89,
Non-malignant breast disorders w/o CC/MCC,601,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3235.89,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3406.2,100,MS-DRG,2724.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3406.2,3235.89,
Cellulitis w MCC,602,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5050.77,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5316.6,100,MS-DRG,4253.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5316.6,5050.77,
Cellulitis w/o MCC,603,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4321.74,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4549.2,100,MS-DRG,3639.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4549.2,4321.74,
"Trauma to the skin, subcut tiss & breast w MCC",604,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3085.98,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3248.4,100,MS-DRG,2598.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3248.4,3085.98,
"Trauma to the skin, subcut tiss & breast w/o MCC",605,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2546.19,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2680.2,100,MS-DRG,2144.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2680.2,2546.19,
Minor skin disorders w MCC,606,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3628.05,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3819,100,MS-DRG,3055.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3819,3628.05,
Minor skin disorders w/o MCC,607,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2946.9,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3102,100,MS-DRG,2481.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3102,2946.9,
Adrenal & pituitary procedures w CC/MCC,614,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,15234.39,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16036.2,100,MS-DRG,12828.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16036.2,15234.39,
Adrenal & pituitary procedures w/o CC/MCC,615,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,15234.39,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16036.2,100,MS-DRG,12828.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16036.2,15234.39,
"Amputat of lower limb for endocrine,nutrit,& metabol dis w MCC",616,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18649.83,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19631.4,100,MS-DRG,15705.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19631.4,18649.83,
"Amputat of lower limb for endocrine,nutrit,& metabol dis w CC",617,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18649.83,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19631.4,100,MS-DRG,15705.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19631.4,18649.83,
"Amputat of lower limb for endocrine,nutrit,& metabol dis w/o CC/MCC",618,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18649.83,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19631.4,100,MS-DRG,15705.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19631.4,18649.83,
O.R. procedures for obesity w MCC,619,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12042.96,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12676.8,100,MS-DRG,10141.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12676.8,12042.96,
O.R. procedures for obesity w CC,620,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12042.96,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12676.8,100,MS-DRG,10141.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12676.8,12042.96,
O.R. procedures for obesity w/o CC/MCC,621,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12042.96,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12676.8,100,MS-DRG,10141.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12676.8,12042.96,
"Skin grafts & wound debrid for endoc, nutrit & metab dis w MCC",622,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13552.32,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14265.6,100,MS-DRG,11412.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14265.6,13552.32,
"Skin grafts & wound debrid for endoc, nutrit & metab dis w CC",623,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13552.32,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14265.6,100,MS-DRG,11412.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14265.6,13552.32,
"Skin grafts & wound debrid for endoc, nutrit & metab dis w/o CC/MCC",624,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13552.32,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14265.6,100,MS-DRG,11412.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14265.6,13552.32,
"Thyroid, parathyroid & thyroglossal procedures w MCC",625,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7583.28,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7982.4,100,MS-DRG,6385.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7982.4,7583.28,
"Thyroid, parathyroid & thyroglossal procedures w CC",626,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7583.28,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7982.4,100,MS-DRG,6385.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7982.4,7583.28,
"Thyroid, parathyroid & thyroglossal procedures w/o CC/MCC",627,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4879.77,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5136.6,100,MS-DRG,4109.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5136.6,4879.77,
"Other endocrine, nutrit & metab O.R. proc w MCC",628,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13183.53,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13877.4,100,MS-DRG,11101.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13877.4,13183.53,
"Other endocrine, nutrit & metab O.R. proc w CC",629,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13183.53,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13877.4,100,MS-DRG,11101.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13877.4,13183.53,
"Other endocrine, nutrit & metab O.R. proc w/o CC/MCC",630,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10237.2,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10776,100,MS-DRG,8620.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10776,10237.2,
Diabetes w MCC,637,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4495.02,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4731.6,100,MS-DRG,3785.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4731.6,4495.02,
Diabetes w CC,638,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4495.02,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4731.6,100,MS-DRG,3785.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4731.6,4495.02,
Diabetes w/o CC/MCC,639,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4248.78,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4472.4,100,MS-DRG,3577.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4472.4,4248.78,
"Miscellaneous disorders of nutrition, metabolism, and fluids and electrolytes with MCC",640,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4714.47,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4962.6,100,MS-DRG,3970.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4962.6,4714.47,
"Miscellaneous disorders of nutrition, metabolism, and fluids and electrolytes w/o MCC",641,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4105.71,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4321.8,100,MS-DRG,3457.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4321.8,4105.71,
Inborn and other discorders of metabolism,642,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4583.37,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4824.6,100,MS-DRG,3859.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4824.6,4583.37,
Endocrine disorders w MCC,643,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5328.36,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5608.8,100,MS-DRG,4487.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5608.8,5328.36,
Endocrine disorders w CC,644,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5328.36,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5608.8,100,MS-DRG,4487.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5608.8,5328.36,
Endocrine disorders w/o CC/MCC,645,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3922.74,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4129.2,100,MS-DRG,3303.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4129.2,3922.74,
Kidney transplant,652,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,26372.19,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,27760.2,100,MS-DRG,22208.16,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27760.2,26372.19,
Major bladder procedures w MCC,653,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,19070.49,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,20074.2,100,MS-DRG,16059.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20074.2,19070.49,
Major bladder procedures w CC,654,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,19070.49,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,20074.2,100,MS-DRG,16059.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20074.2,19070.49,
Major bladder procedures w/o CC/MCC,655,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,19070.49,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,20074.2,100,MS-DRG,16059.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20074.2,19070.49,
Kidney & ureter procedures for neoplasm w MCC,656,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,15735.42,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16563.6,100,MS-DRG,13250.88,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16563.6,15735.42,
Kidney & ureter procedures forneoplasm w CC,657,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,15735.42,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16563.6,100,MS-DRG,13250.88,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16563.6,15735.42,
Kidney & ureter procedures for neoplasm w/o CC/MCC,658,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,15735.42,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16563.6,100,MS-DRG,13250.88,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16563.6,15735.42,
Kidney & ureter procedures for non-neoplasm w MCC,659,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11583.54,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12193.2,100,MS-DRG,9754.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12193.2,11583.54,
Kidney & ureter procedures for non-neoplasm w CC,660,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11583.54,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12193.2,100,MS-DRG,9754.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12193.2,11583.54,
Kidney & ureter procedures for non-neoplasm w/o CC/MCC,661,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8489.01,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8935.8,100,MS-DRG,7148.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8935.8,8489.01,
Minor bladder procedures w MCC,662,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6547.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6892.2,100,MS-DRG,5513.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6892.2,6547.59,
Minor bladder procedures w CC,663,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6547.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6892.2,100,MS-DRG,5513.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6892.2,6547.59,
Minor bladder procedures w/o CC/MCC,664,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4927.08,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5186.4,100,MS-DRG,4149.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5186.4,4927.08,
Prostatectomy w MCC,665,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7178.01,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7555.8,100,MS-DRG,6044.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7555.8,7178.01,
Prostatectomy w CC,666,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7178.01,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7555.8,100,MS-DRG,6044.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7555.8,7178.01,
Prostatectomy w/o CC/MCC,667,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5463.45,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5751,100,MS-DRG,4600.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5751,5463.45,
Transurethral procedures w MCC,668,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4141.05,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4359,100,MS-DRG,3487.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4359,4141.05,
Transurethral procedures w CC,669,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4141.05,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4359,100,MS-DRG,3487.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4359,4141.05,
Transurethral procedures w/o CC/MCC,670,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3171.48,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3338.4,100,MS-DRG,2670.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3338.4,3171.48,
Urethral procedures w CC/MCC,671,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4164.99,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4384.2,100,MS-DRG,3507.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4384.2,4164.99,
Urethral procedures w/o CC/MCC,672,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3308.28,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3482.4,100,MS-DRG,2785.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3482.4,3308.28,
Other kidney & urinary tract procedures w MCC,673,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,15809.52,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16641.6,100,MS-DRG,13313.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16641.6,15809.52,
Other kidney & urinary tract procedures w CC,674,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,15809.52,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16641.6,100,MS-DRG,13313.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16641.6,15809.52,
Other kidney & urinary tract procedures w/o CC/MCC,675,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,15809.52,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,16641.6,100,MS-DRG,13313.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,16641.6,15809.52,
Renal failure w MCC,682,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7529.7,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7926,100,MS-DRG,6340.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7926,7529.7,
Renal failure w CC,683,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7529.7,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7926,100,MS-DRG,6340.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7926,7529.7,
Renal failure w/o CC/MCC,684,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7529.7,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7926,100,MS-DRG,6340.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7926,7529.7,
Kidney & urinary tract neoplasms w MCC,686,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5253.12,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5529.6,100,MS-DRG,4423.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5529.6,5253.12,
Kidney & urinary tract neoplasms w CC,687,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5253.12,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5529.6,100,MS-DRG,4423.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5529.6,5253.12,
Kidney & urinary tract neoplasms w/o CC/MCC,688,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4226.55,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4449,100,MS-DRG,3559.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4449,4226.55,
Kidney & urinary tract infections w MCC,689,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4916.82,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5175.6,100,MS-DRG,4140.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5175.6,4916.82,
Kidney & urinary tract infections w/o MCC,690,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3987.72,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4197.6,100,MS-DRG,3358.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4197.6,3987.72,
Urinary stones w MCC,693,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2334.72,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2457.6,100,MS-DRG,1966.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2457.6,2334.72,
Urinary stones w/o MCC,694,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2334.72,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2457.6,100,MS-DRG,1966.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2457.6,2334.72,
Kidney & urinary tract signs & symptoms w MCC,695,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3706.71,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3901.8,100,MS-DRG,3121.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3901.8,3706.71,
Kidney & urinary tract signs & symptoms w/o MCC,696,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3141.27,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3306.6,100,MS-DRG,2645.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3306.6,3141.27,
Urethral stricture,697,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3385.23,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3563.4,100,MS-DRG,2850.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3563.4,3385.23,
Other kidney & urinary tract diagnoses w MCC,698,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4747.53,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4997.4,100,MS-DRG,3997.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4997.4,4747.53,
Other kidney & urinary tract diagnoses w CC,699,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4747.53,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4997.4,100,MS-DRG,3997.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4997.4,4747.53,
Other kidney & urinary tract diagnoses w/o CC/MCC,700,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4509.84,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4747.2,100,MS-DRG,3797.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4747.2,4509.84,
Major male pelvic procedures w CC/MCC,707,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10279.95,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10821,100,MS-DRG,8656.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10821,10279.95,
Major male pelvic procedures w/o CC/MCC,708,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8346.51,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8785.8,100,MS-DRG,7028.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8785.8,8346.51,
Penis procedures w CC/MCC,709,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5682.9,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5982,100,MS-DRG,4785.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5982,5682.9,
Penis procedures w/o CC/MCC,710,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5682.9,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5982,100,MS-DRG,4785.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5982,5682.9,
Testes procedures w CC/MCC,711,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5076.99,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5344.2,100,MS-DRG,4275.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5344.2,5076.99,
Testes procedures w/o CC/MCC,712,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3286.62,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3459.6,100,MS-DRG,2767.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3459.6,3286.62,
Transurethral prostatectomy w CC/MCC,713,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5625.33,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5921.4,100,MS-DRG,4737.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5921.4,5625.33,
Transurethral prostatectomy w/o CC/MCC,714,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4439.16,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4672.8,100,MS-DRG,3738.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4672.8,4439.16,
Other male reproductive system O.R. proc for malignancy w CC/MCC,715,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6391.98,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6728.4,100,MS-DRG,5382.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6728.4,6391.98,
Other male reproductive system O.R. proc for malignancy w/o CC/MCC,716,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6391.98,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6728.4,100,MS-DRG,5382.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6728.4,6391.98,
Other male reproductive system O.R. proc exc malignancy w CC/MCC,717,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4658.61,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4903.8,100,MS-DRG,3923.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4903.8,4658.61,
Other male reproductive system O.R. proc exc malignancy w/o CC/MCC,718,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4658.61,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4903.8,100,MS-DRG,3923.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4903.8,4658.61,
"Malignancy, male reproductive system w MCC",722,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4883.76,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5140.8,100,MS-DRG,4112.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5140.8,4883.76,
"Malignancy, male reproductive system w CC",723,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4883.76,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5140.8,100,MS-DRG,4112.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5140.8,4883.76,
"Malignancy, male reproductive system w/o CC/MCC",724,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3671.37,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3864.6,100,MS-DRG,3091.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3864.6,3671.37,
Benign prostatic hypertrophy w MCC,725,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3566.49,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3754.2,100,MS-DRG,3003.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3754.2,3566.49,
Benign prostatic hypertrophy w/o MCC,726,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2766.21,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2911.8,100,MS-DRG,2329.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2911.8,2766.21,
Inflammation of the male reproductive system w MCC,727,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3573.9,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3762,100,MS-DRG,3009.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3762,3573.9,
Inflammation of the male reproductive system w/o MCC,728,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3573.9,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3762,100,MS-DRG,3009.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3762,3573.9,
Other male reproductive system diagnoses w CC/MCC,729,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3051.78,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3212.4,100,MS-DRG,2569.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3212.4,3051.78,
Other male reproductive system diagnoses w/o CC/MCC,730,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,1899.81,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,1999.8,100,MS-DRG,1599.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1999.8,1899.81,
"Pelvic evisceration, rad hysterectomy & rad vulvectomy w CC/MCC",734,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13615.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14332.2,100,MS-DRG,11465.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14332.2,13615.59,
"Pelvic evisceration, rad hysterectomy & rad vulvectomy w/o CC/MCC",735,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13615.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14332.2,100,MS-DRG,11465.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14332.2,13615.59,
Uterine & adnexa proc for ovarian or adnexal malignancy w MCC,736,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12028.71,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12661.8,100,MS-DRG,10129.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12661.8,12028.71,
Uterine & adnexa proc for ovarian or adnexal malignancy w CC,737,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12028.71,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12661.8,100,MS-DRG,10129.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12661.8,12028.71,
Uterine & adnexa proc for ovarian or adnexal malignancy w/o CC/MCC,738,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12028.71,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12661.8,100,MS-DRG,10129.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12661.8,12028.71,
"Uterine,adnexa proc for non-ovarian/adnexal malig w MCC",739,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7730.91,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8137.8,100,MS-DRG,6510.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8137.8,7730.91,
"Uterine,adnexa proc for non-ovarian/adnexal malig w CC",740,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7730.91,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8137.8,100,MS-DRG,6510.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8137.8,7730.91,
"Uterine,adnexa proc for non-ovarian/adnexal malig w/o CC/MCC",741,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5904.63,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6215.4,100,MS-DRG,4972.32,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6215.4,5904.63,
Uterine & adnexa proc for non-malignancy w CC/MCC,742,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6356.64,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6691.2,100,MS-DRG,5352.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6691.2,6356.64,
Uterine & adnexa proc for non-malignancy w/o CC/MCC,743,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5393.34,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5677.2,100,MS-DRG,4541.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5677.2,5393.34,
"D&C, conization, laparoscopy & tubal interruption w CC/MCC",744,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3758.58,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3956.4,100,MS-DRG,3165.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3956.4,3758.58,
"D&C, conization, laparoscopy & tubal interruption w/o CC/MCC",745,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3508.92,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3693.6,100,MS-DRG,2954.88,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3693.6,3508.92,
"Vagina, cervix & vulva procedures w CC/MCC",746,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3612.66,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3802.8,100,MS-DRG,3042.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3802.8,3612.66,
"Vagina, cervix & vulva procedures w/o CC/MCC",747,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3612.66,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3802.8,100,MS-DRG,3042.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3802.8,3612.66,
Female reproductive system reconstructive procedures,748,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4827.9,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5082,100,MS-DRG,4065.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5082,4827.9,
Other female reproductive system O.R. procedures w CC/MCC,749,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10878.45,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11451,100,MS-DRG,9160.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11451,10878.45,
Other female reproductive system O.R. procedures w/o CC/MCC,750,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10878.45,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11451,100,MS-DRG,9160.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11451,10878.45,
"Malignancy, female reproductive system w MCC",754,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4915.68,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5174.4,100,MS-DRG,4139.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5174.4,4915.68,
"Malignancy, female reproductive system w CC",755,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4915.68,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5174.4,100,MS-DRG,4139.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5174.4,4915.68,
"Malignancy, female reproductive system w/o CC/MCC",756,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3051.21,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3211.8,100,MS-DRG,2569.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3211.8,3051.21,
"Infections, female reproductive system w MCC",757,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4337.7,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4566,100,MS-DRG,3652.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4566,4337.7,
"Infections, female reproductive system w CC",758,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4337.7,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4566,100,MS-DRG,3652.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4566,4337.7,
"Infections, female reproductive system w/o CC/MCC",759,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4337.7,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4566,100,MS-DRG,3652.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4566,4337.7,
Menstrual & other female reproductive system disorders w CC/MCC,760,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3132.72,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3297.6,100,MS-DRG,2638.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3297.6,3132.72,
Menstrual & other female reproductive system disorders w/o CC/MCC,761,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3132.72,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3297.6,100,MS-DRG,2638.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3297.6,3132.72,
Vaginal delivery w O.R. proc except steril &/or D&C,768,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7266.93,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7649.4,100,MS-DRG,6119.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7649.4,7266.93,
Postpartum & post abortion diagnoses w O.R. procedure,769,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3284.91,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3457.8,100,MS-DRG,2766.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3457.8,3284.91,
"Abortion w D&C, aspiration curettage or hysterotomy",770,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2138.07,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2250.6,100,MS-DRG,1800.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2250.6,2138.07,
Postpartum & post abortion diagnoses w/o O.R. procedure,776,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2419.65,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2547,100,MS-DRG,2037.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2547,2419.65,
Abortion w/o D&C,779,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,1865.04,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,1963.2,100,MS-DRG,1570.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1963.2,1865.04,
Cesarean Section with Sterilization with MCC,783,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6165.12,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6489.6,100,MS-DRG,5191.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6489.6,6165.12,
Cesarean Section with Sterilization with CC,784,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6165.12,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6489.6,100,MS-DRG,5191.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6489.6,6165.12,
Cesarean Section with Sterilization without CC/MCC,785,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4440.3,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4674,100,MS-DRG,3739.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4674,4440.3,
Cesarean Section without Sterilization with MCC,786,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6165.12,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6489.6,100,MS-DRG,5191.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6489.6,6165.12,
Cesarean Section without Sterilization with CC,787,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6165.12,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6489.6,100,MS-DRG,5191.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6489.6,6165.12,
Cesarean Section without Sterilization without CC/MCC,788,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4440.3,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4674,100,MS-DRG,3739.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4674,4440.3,
"Neonates, died or transferred to another acute care facility",789,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10137.45,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10671,100,MS-DRG,8536.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10671,10137.45,
"Extreme immaturity or respiratory distress syndrome, neonate",790,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,31657.23,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,33323.4,100,MS-DRG,26658.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,33323.4,31657.23,
Prematurity w major problems,791,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13931.37,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,14664.6,100,MS-DRG,11731.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,14664.6,13931.37,
Prematurity w/o major problems,792,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3250.71,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3421.8,100,MS-DRG,2737.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3421.8,3250.71,
Full term neonate w major problems,793,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2913.27,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3066.6,100,MS-DRG,2453.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3066.6,2913.27,
Neonate w other significant problems,794,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,1068.18,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,1124.4,100,MS-DRG,899.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1124.4,1068.18,
Normal newborn,795,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,683.43,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,719.4,100,MS-DRG,575.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,719.4,683.43,
Vaginal Delivery with Sterilization/D&C with MCC,796,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3198.27,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3366.6,100,MS-DRG,2693.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3366.6,3198.27,
Vaginal Delivery with Sterilization/D&C with CC,797,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3198.27,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3366.6,100,MS-DRG,2693.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3366.6,3198.27,
Vaginal Delivery with Sterilization/D&C without CC/MCC,798,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3198.27,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3366.6,100,MS-DRG,2693.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3366.6,3198.27,
Splenectomy w MCC,799,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18518.16,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19492.8,100,MS-DRG,15594.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19492.8,18518.16,
Splenectomy w CC,800,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18518.16,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19492.8,100,MS-DRG,15594.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19492.8,18518.16,
Splenectomy w/o CC/MCC,801,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8667.42,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9123.6,100,MS-DRG,7298.88,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9123.6,8667.42,
Other O.R. proc of the blood & blood forming organs w MCC,802,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6206.73,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6533.4,100,MS-DRG,5226.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6533.4,6206.73,
Other O.R. proc of the blood & blood forming organs w CC,803,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6206.73,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6533.4,100,MS-DRG,5226.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6533.4,6206.73,
Other O.R. proc of the blood & blood forming organs w/o CC/MCC,804,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6206.73,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6533.4,100,MS-DRG,5226.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6533.4,6206.73,
Vaginal Delivery without Sterilization/D&C with MCC,805,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2803.26,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2950.8,100,MS-DRG,2360.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2950.8,2803.26,
Vaginal Delivery without Sterilization/D&C with CC,806,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2803.26,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2950.8,100,MS-DRG,2360.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2950.8,2803.26,
Vaginal Delivery without Sterilization/D&C without CC/MCC,807,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,1891.83,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,1991.4,100,MS-DRG,1593.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1991.4,1891.83,
Major hematol/immun diag exc sickle cell crisis & coagul w MCC,808,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7237.86,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7618.8,100,MS-DRG,6095.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7618.8,7237.86,
Major hematol/immun diag exc sickle cell crisis & coagul w CC,809,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7237.86,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7618.8,100,MS-DRG,6095.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7618.8,7237.86,
Major hematol/immun diag exc sickle cell crisis & coagul w/o CC/MCC,810,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7237.86,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7618.8,100,MS-DRG,6095.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7618.8,7237.86,
Red blood cell disorders w MCC,811,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4077.21,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4291.8,100,MS-DRG,3433.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4291.8,4077.21,
Red blood cell disorders w/o MCC,812,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,1682.64,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,1771.2,100,MS-DRG,1416.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1771.2,1682.64,
Coagulation disorders,813,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5682.33,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5981.4,100,MS-DRG,4785.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5981.4,5682.33,
Reticuloendothelial & immunity disorders w MCC,814,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5558.64,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5851.2,100,MS-DRG,4680.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5851.2,5558.64,
Reticuloendothelial & immunity disorders w CC,815,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5558.64,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5851.2,100,MS-DRG,4680.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5851.2,5558.64,
Reticuloendothelial & immunity disorders w/o CC/MCC,816,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4130.79,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4348.2,100,MS-DRG,3478.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4348.2,4130.79,
Other Antepartum Diagnoses with O.R. Procedure with MCC,817,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,1975.62,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2079.6,100,MS-DRG,1663.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2079.6,1975.62,
Other Antepartum Diagnoses with O.R. Procedure with CC,818,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,1975.62,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2079.6,100,MS-DRG,1663.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2079.6,1975.62,
Other Antepartum Diagnoses with O.R. Procedure without CC/MCC,819,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,1738.5,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,1830,100,MS-DRG,1464,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1830,1738.5,
Lymphoma & leukemia w major O.R. procedure w MCC,820,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,19292.22,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,20307.6,100,MS-DRG,16246.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20307.6,19292.22,
Lymphoma & leukemia w major O.R. procedure w CC,821,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,19292.22,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,20307.6,100,MS-DRG,16246.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,20307.6,19292.22,
Lymphoma & leukemia w major O.R. procedure w/o CC/MCC,822,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7347.87,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7734.6,100,MS-DRG,6187.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7734.6,7347.87,
Lymphoma & non-acute leukemia w other O.R. proc w MCC,823,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11016.39,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11596.2,100,MS-DRG,9276.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11596.2,11016.39,
Lymphoma & non-acute leukemia w other O.R. proc w CC,824,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11016.39,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,11596.2,100,MS-DRG,9276.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,11596.2,11016.39,
Lymphoma & non-acute leukemia w other O.R. proc w/o CC/MCC,825,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5992.98,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6308.4,100,MS-DRG,5046.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6308.4,5992.98,
Myeloprolif disord or poorly diff neopl w maj O.R. proc w MCC,826,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14422.14,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,15181.2,100,MS-DRG,12144.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15181.2,14422.14,
Myeloprolif disord or poorly diff neopl w maj O.R. proc w CC,827,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14422.14,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,15181.2,100,MS-DRG,12144.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15181.2,14422.14,
Myeloprolif disord or poorly diff neopl w maj O.R. proc w/o CC/MCC,828,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9760.68,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10274.4,100,MS-DRG,8219.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10274.4,9760.68,
Myeloprolif disord or poorly diff neopl w other O.R. proc w CC/MCC,829,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5985,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6300,100,MS-DRG,5040,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6300,5985,
Myeloprolif disord or poorly diff neopl w other O.R. proc w/o CC/MCC,830,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5985,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6300,100,MS-DRG,5040,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6300,5985,
Other Antepartum Diagnoses without O.R. Procedure with MCC,831,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,1975.62,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2079.6,100,MS-DRG,1663.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2079.6,1975.62,
Other Antepartum Diagnoses without O.R. Procedure with CC,832,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,1975.62,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2079.6,100,MS-DRG,1663.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2079.6,1975.62,
Other Antepartum Diagnoses without O.R. Procedure without CC/MCC,833,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,1738.5,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,1830,100,MS-DRG,1464,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1830,1738.5,
Acute leukemia w/o major O.R. procedure w MCC,834,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13266.75,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13965,100,MS-DRG,11172,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13965,13266.75,
Acute leukemia w/o major O.R. procedure w CC,835,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,13266.75,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13965,100,MS-DRG,11172,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13965,13266.75,
Acute leukemia w/o major O.R. procedure w/o CC/MCC,836,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5931.99,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6244.2,100,MS-DRG,4995.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6244.2,5931.99,
Chemo w acute leukemia as sdx or w  high dose chemo agent w MCC,837,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14669.52,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,15441.6,100,MS-DRG,12353.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15441.6,14669.52,
Chemo w acute leukemia as sdx or w high dose chemo agent w CC,838,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14669.52,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,15441.6,100,MS-DRG,12353.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15441.6,14669.52,
Chemo w acute leukemia as sdx w/o CC/MCC,839,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,14669.52,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,15441.6,100,MS-DRG,12353.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,15441.6,14669.52,
Lymphoma & non-acute leukemia w MCC,840,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7691.01,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8095.8,100,MS-DRG,6476.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8095.8,7691.01,
Lymphoma & non-acute leukemia w CC,841,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7691.01,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8095.8,100,MS-DRG,6476.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8095.8,7691.01,
Lymphoma & non-acute leukemia w/o CC/MCC,842,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5187.57,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5460.6,100,MS-DRG,4368.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5460.6,5187.57,
Other myeloprolif dis or poorly diff neopl diag w MCC,843,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5959.35,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6273,100,MS-DRG,5018.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6273,5959.35,
Other myeloprolif dis or poorly diff neopl diag w CC,844,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5959.35,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6273,100,MS-DRG,5018.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6273,5959.35,
Other myeloprolif dis or poorly diff neopl diag w/o CC/MCC,845,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5120.31,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5389.8,100,MS-DRG,4311.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5389.8,5120.31,
Chemotherapy w/o acute leukemia as secondary diagnosis w MCC,846,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2441.88,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2570.4,100,MS-DRG,2056.32,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.4,2441.88,
Chemotherapy w/o acute leukemia as secondary diagnosis w CC,847,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2441.88,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2570.4,100,MS-DRG,2056.32,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.4,2441.88,
Chemotherapy w/o acute leukemia as secondary diagnosis w/o CC/MCC,848,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2441.88,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2570.4,100,MS-DRG,2056.32,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2570.4,2441.88,
Radiotherapy,849,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5617.35,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5913,100,MS-DRG,4730.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5913,5617.35,
Infectious & parasitic diseases w O.R. procedure w MCC,853,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18973.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19972.2,100,MS-DRG,15977.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19972.2,18973.59,
Infectious & parasitic diseases w O.R. procedure w CC,854,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18973.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19972.2,100,MS-DRG,15977.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19972.2,18973.59,
Infectious & parasitic diseases w O.R. procedure w/o CC/MCC,855,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18973.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19972.2,100,MS-DRG,15977.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19972.2,18973.59,
Postoperative or post-traumatic infections w O.R. proc w MCC,856,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18973.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19972.2,100,MS-DRG,15977.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19972.2,18973.59,
Postoperative or post-traumatic infections w O.R. proc w CC,857,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18973.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19972.2,100,MS-DRG,15977.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19972.2,18973.59,
Postoperative or post-traumatic infections w O.R. proc w/o CC/MCC,858,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18973.59,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19972.2,100,MS-DRG,15977.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19972.2,18973.59,
Postoperative & post-traumatic infections w MCC,862,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5712.54,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6013.2,100,MS-DRG,4810.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.2,5712.54,
Postoperative & post-traumatic infections w/o MCC,863,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5712.54,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6013.2,100,MS-DRG,4810.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6013.2,5712.54,
Fever and Inflammatory Conditions,864,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,5303.85,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5583,100,MS-DRG,4466.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5583,5303.85,
Viral illness w MCC,865,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3752.31,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3949.8,100,MS-DRG,3159.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3949.8,3752.31,
Viral illness w/o MCC,866,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3233.04,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3403.2,100,MS-DRG,2722.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3403.2,3233.04,
Other infectious & parasitic diseases diagnoses w MCC,867,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7526.85,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7923,100,MS-DRG,6338.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7923,7526.85,
Other infectious & parasitic diseases diagnoses w CC,868,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7526.85,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7923,100,MS-DRG,6338.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7923,7526.85,
Other infectious & parasitic diseases diagnoses w/o CC/MCC,869,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7526.85,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7923,100,MS-DRG,6338.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7923,7526.85,
Septicemia or severe sepsis w MV 96> hours,870,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9223.74,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9709.2,100,MS-DRG,7767.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9709.2,9223.74,
Septicemia or severe sepsis w/o MV 96+ hours w MCC,871,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9223.74,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9709.2,100,MS-DRG,7767.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9709.2,9223.74,
Septicemia or severe sepsis w/o MV 96+ hours w/o MCC,872,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9223.74,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9709.2,100,MS-DRG,7767.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9709.2,9223.74,
O.R. procedure w principal diagnoses of mental illness,876,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12604.41,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,13267.8,100,MS-DRG,10614.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,13267.8,12604.41,
Acute adjustment reaction & psychosocial dysfunction,880,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3471.3,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3654,100,MS-DRG,2923.2,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3654,3471.3,
Depressive neuroses,881,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4749.24,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4999.2,100,MS-DRG,3999.36,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4999.2,4749.24,
Neuroses except depressive,882,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4000.26,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4210.8,100,MS-DRG,3368.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4210.8,4000.26,
Disorders of personality & impulse control,883,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4852.41,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5107.8,100,MS-DRG,4086.24,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5107.8,4852.41,
Organic disturbances & intellectual disability,884,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4798.83,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5051.4,100,MS-DRG,4041.12,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5051.4,4798.83,
Psychoses,885,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6133.2,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6456,100,MS-DRG,5164.8,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6456,6133.2,
Behavioral & developmental disorders,886,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4841.01,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,5095.8,100,MS-DRG,4076.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,5095.8,4841.01,
Other mental disorder diagnoses,887,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3971.76,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4180.8,100,MS-DRG,3344.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4180.8,3971.76,
"Alcohol/drug abuse or dependence, left ama",894,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2226.42,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2343.6,100,MS-DRG,1874.88,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2343.6,2226.42,
Alcohol/drug abuse or dependence w rehabilitation therapy,895,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4192.35,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4413,100,MS-DRG,3530.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4413,4192.35,
Alcohol/drug abuse or dependence w/o rehabilitation therapy w MCC,896,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2278.29,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2398.2,100,MS-DRG,1918.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2398.2,2278.29,
Alcohol/drug abuse or dependence w/o rehabilitation therapy w/o MCC,897,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2278.29,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2398.2,100,MS-DRG,1918.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2398.2,2278.29,
Wound debridements for injuries w MCC,901,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11639.97,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12252.6,100,MS-DRG,9802.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12252.6,11639.97,
Wound debridements for injuries w CC,902,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11639.97,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12252.6,100,MS-DRG,9802.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12252.6,11639.97,
Wound debridements for injuries w/o CC/MCC,903,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11639.97,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12252.6,100,MS-DRG,9802.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12252.6,11639.97,
Skin grafts for injuries w CC/MCC,904,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9407.85,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9903,100,MS-DRG,7922.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9903,9407.85,
Skin grafts for injuries w/o CC/MCC,905,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9407.85,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,9903,100,MS-DRG,7922.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,9903,9407.85,
Hand procedures for injuries,906,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4162.71,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4381.8,100,MS-DRG,3505.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4381.8,4162.71,
Other O.R. procedures for injuries w MCC,907,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10341.51,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10885.8,100,MS-DRG,8708.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10885.8,10341.51,
Other O.R. procedures for injuries w CC,908,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10341.51,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10885.8,100,MS-DRG,8708.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10885.8,10341.51,
Other O.R. procedures for injuries w/o CC/MCC,909,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8459.37,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8904.6,100,MS-DRG,7123.68,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8904.6,8459.37,
Traumatic injury w MCC,913,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4031.04,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4243.2,100,MS-DRG,3394.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4243.2,4031.04,
Traumatic injury w/o MCC,914,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3427.98,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3608.4,100,MS-DRG,2886.72,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3608.4,3427.98,
Allergic reactions w MCC,915,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2547.9,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2682,100,MS-DRG,2145.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2682,2547.9,
Allergic reactions w/o MCC,916,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,1977.9,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2082,100,MS-DRG,1665.6,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2082,1977.9,
Poisoning & toxic effects of drugs w MCC,917,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3962.07,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4170.6,100,MS-DRG,3336.48,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4170.6,3962.07,
Poisoning & toxic effects of drugs w/o MCC,918,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3133.29,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3298.2,100,MS-DRG,2638.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3298.2,3133.29,
Complications of treatment w MCC,919,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4605.03,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4847.4,100,MS-DRG,3877.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4847.4,4605.03,
Complications of treatment w CC,920,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4605.03,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4847.4,100,MS-DRG,3877.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4847.4,4605.03,
Complications of treatment w/o CC/MCC,921,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4256.76,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4480.8,100,MS-DRG,3584.64,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4480.8,4256.76,
"Other injury, poisoning & toxic effect diag w MCC",922,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4616.43,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4859.4,100,MS-DRG,3887.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4859.4,4616.43,
"Other injury, poisoning & toxic effect diag w/o MCC",923,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3421.14,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,3601.2,100,MS-DRG,2880.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,3601.2,3421.14,
Extensive burns or full thickness burns w MV 96+ hrs w skin graft,927,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,80457.21,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,84691.8,100,MS-DRG,67753.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,84691.8,80457.21,
Full thickness burn w skin graft or inhal inj w CC/MCC,928,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,24212.46,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,25486.8,100,MS-DRG,20389.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,25486.8,24212.46,
Full thickness burn w skin graft or inhal inj w/o CC/MCC,929,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9734.46,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10246.8,100,MS-DRG,8197.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10246.8,9734.46,
Extensive burns or full thickness burns w MV 96+ hrs w/o skin graft,933,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10188.75,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10725,100,MS-DRG,8580,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10725,10188.75,
Full thickness burn w/o skin grft or inhal inj,934,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,8081.46,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8506.8,100,MS-DRG,6805.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8506.8,8081.46,
Non-extensive burns,935,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6629.1,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,6978,100,MS-DRG,5582.4,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,6978,6629.1,
O.R. proc w diagnoses of other contact w health services w MCC,939,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7722.36,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8128.8,100,MS-DRG,6503.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8128.8,7722.36,
O.R. proc w diagnoses of other contact w health services w CC,940,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7722.36,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8128.8,100,MS-DRG,6503.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8128.8,7722.36,
O.R. proc w diagnoses of other contact w health services w/o CC/MCC,941,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,7722.36,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,8128.8,100,MS-DRG,6503.04,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,8128.8,7722.36,
Rehabilitation w CC/MCC,945,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12200.28,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12842.4,100,MS-DRG,10273.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12842.4,12200.28,
Rehabilitation w/o CC/MCC,946,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,12200.28,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12842.4,100,MS-DRG,10273.92,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12842.4,12200.28,
Signs & symptoms w MCC,947,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4530.93,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4769.4,100,MS-DRG,3815.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4769.4,4530.93,
Signs & symptoms w/o MCC,948,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,3962.64,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4171.2,100,MS-DRG,3336.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4171.2,3962.64,
Aftercare w CC/MCC,949,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,2366.64,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,2491.2,100,MS-DRG,1992.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,2491.2,2366.64,
Aftercare w/o CC/MCC,950,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,1642.17,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,1728.6,100,MS-DRG,1382.88,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,1728.6,1642.17,
Other factors influencing health status,951,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,4110.84,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,4327.2,100,MS-DRG,3461.76,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,4327.2,4110.84,
Craniotomy for multiple significant trauma,955,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,39884.04,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,41983.2,100,MS-DRG,33586.56,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,41983.2,39884.04,
"Limb reattachment, hip & femur proc for multiple significant trauma",956,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,18593.97,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,19572.6,100,MS-DRG,15658.08,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,19572.6,18593.97,
Other O.R. procedures for multiple significant trauma w MCC,957,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,28273.71,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,29761.8,100,MS-DRG,23809.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29761.8,28273.71,
Other O.R. procedures for multiple significant trauma w CC,958,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,28273.71,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,29761.8,100,MS-DRG,23809.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29761.8,28273.71,
Other O.R. procedures for multiple significant trauma w/o CC/MCC,959,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,28273.71,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,29761.8,100,MS-DRG,23809.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,29761.8,28273.71,
Other multiple significant trauma w MCC,963,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10444.68,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10994.4,100,MS-DRG,8795.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10994.4,10444.68,
Other multiple significant trauma w CC,964,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10444.68,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10994.4,100,MS-DRG,8795.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10994.4,10444.68,
Other multiple significant trauma w/o CC/MCC,965,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,10444.68,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10994.4,100,MS-DRG,8795.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10994.4,10444.68,
HIV w extensive O.R. procedure w MCC,969,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,25694.46,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,27046.8,100,MS-DRG,21637.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27046.8,25694.46,
HIV w extensive O.R. procedure w/o MCC,970,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,25694.46,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,27046.8,100,MS-DRG,21637.44,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,27046.8,25694.46,
HIV w major related condition w MCC,974,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11784.18,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12404.4,100,MS-DRG,9923.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12404.4,11784.18,
HIV w major related condition w CC,975,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11784.18,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12404.4,100,MS-DRG,9923.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12404.4,11784.18,
HIV w major related condition w/o CC/MCC,976,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,11784.18,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,12404.4,100,MS-DRG,9923.52,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,12404.4,11784.18,
HIV w or w/o other related condition,977,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,6730.56,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,7084.8,100,MS-DRG,5667.84,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,7084.8,6730.56,
Extensive O.R. procedure unrelated to principal diagnosis w MCC,981,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,20635.14,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,21721.2,100,MS-DRG,17376.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21721.2,20635.14,
Extensive O.R. procedure unrelated to principal diagnosis w CC,982,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,20635.14,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,21721.2,100,MS-DRG,17376.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21721.2,20635.14,
Extensive O.R. procedure unrelated to principal diagnosis w/o CC/MCC,983,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,20635.14,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,21721.2,100,MS-DRG,17376.96,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,21721.2,20635.14,
Non-extensive O.R. proc unrelated to principal diagnosis w MCC,987,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9952.77,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10476.6,100,MS-DRG,8381.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10476.6,9952.77,
Non-extensive O.R. proc unrelated to principal diagnosis w CC,988,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9952.77,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10476.6,100,MS-DRG,8381.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10476.6,9952.77,
Non-extensive O.R. proc unrelated to principal diagnosis w/o CC/MCC,989,MS-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,9952.77,100,MS-DRG,,case rate,100% Blue Cross MS-DRG rate,10476.6,100,MS-DRG,8381.28,case rate,100% Blue Cross MS-DRG rate,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,,,,,Other,Not Separately reimbursable,10476.6,9952.77,
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT,11,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21971.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21971.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21971.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,21971.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21971.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22630.85,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,21971.7,22630.85,
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT,12,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25269.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25269.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25269.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,25269.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25269.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26027.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,25269.81,26027.91,
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT,13,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31456.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,31456.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,31456.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,31456.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,31456.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,32400.3,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,31456.6,32400.3,
LIVER TRANSPLANT AND/OR INTESTINAL TRANSPLANT,14,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,67242.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,67242.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,67242.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,67242.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,67242.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,69259.89,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,67242.62,69259.89,
HEART AND/OR LUNG TRANSPLANT,21,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,41730.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,41730.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,41730.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,41730.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,41730.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,42982.81,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,41730.88,42982.81,
HEART AND/OR LUNG TRANSPLANT,22,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,45376.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,45376.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,45376.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,45376.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,45376.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,46738.27,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,45376.96,46738.27,
HEART AND/OR LUNG TRANSPLANT,23,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,62352.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,62352.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,62352.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,62352.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,62352.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,64223,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,62352.43,64223,
HEART AND/OR LUNG TRANSPLANT,24,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,111047.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,111047.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,111047.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,111047.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,111047.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,114378.68,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,111047.26,114378.68,
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE,41,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22931.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22931.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22931.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,22931.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22931.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23619.42,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,22931.48,23619.42,
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE,42,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25840.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25840.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25840.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,25840.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25840.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26615.86,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,25840.64,26615.86,
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE,43,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,41876.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,41876.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,41876.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,41876.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,41876.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,43132.76,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,41876.47,43132.76,
TRACHEOSTOMY WITH MV >96 HOURS WITH EXTENSIVE PROCEDURE,44,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,66782.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,66782.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,66782.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,66782.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,66782.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,68785.6,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,66782.14,68785.6,
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE,51,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15425.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15425.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15425.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15425.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15425.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15888.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15425.81,15888.58,
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE,52,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19867.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19867.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19867.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,19867.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19867.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20463.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,19867.74,20463.77,
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE,53,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30089.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30089.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30089.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,30089.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30089.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30992.6,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,30089.9,30992.6,
TRACHEOSTOMY WITH MV >96 HOURS WITHOUT EXTENSIVE PROCEDURE,54,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,43560.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,43560.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,43560.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,43560.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,43560.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,44867.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,43560.21,44867.02,
PANCREAS TRANSPLANT,61,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20578.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20578.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20578.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,20578.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20578.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21195.39,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,20578.05,21195.39,
PANCREAS TRANSPLANT,62,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27515.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,27515.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,27515.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,27515.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,27515.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28341.23,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,27515.76,28341.23,
PANCREAS TRANSPLANT,63,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34364.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,34364.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,34364.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,34364.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,34364.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,35395.26,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,34364.33,35395.26,
PANCREAS TRANSPLANT,64,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,48372.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,48372.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,48372.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,48372.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,48372.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,49823.94,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,48372.76,49823.94,
ALLOGENEIC BONE MARROW TRANSPLANT,71,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28151.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28151.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28151.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,28151.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28151.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28996.21,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,28151.66,28996.21,
ALLOGENEIC BONE MARROW TRANSPLANT,72,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29633.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29633.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29633.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,29633.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29633.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30522.01,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,29633.02,30522.01,
ALLOGENEIC BONE MARROW TRANSPLANT,73,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,36953.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,36953.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,36953.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,36953.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,36953.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,38062.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,36953.93,38062.54,
ALLOGENEIC BONE MARROW TRANSPLANT,74,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75611.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,75611.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,75611.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,75611.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,75611.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,77879.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,75611.37,77879.71,
AUTOLOGOUS BONE MARROW TRANSPLANT,81,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11299.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11299.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11299.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11299.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11299.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11638.84,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11299.85,11638.84,
AUTOLOGOUS BONE MARROW TRANSPLANT,82,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16109.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16109.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16109.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16109.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16109.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16592.43,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16109.15,16592.43,
AUTOLOGOUS BONE MARROW TRANSPLANT,83,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19121.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19121.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19121.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,19121.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19121.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19695.13,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,19121.49,19695.13,
AUTOLOGOUS BONE MARROW TRANSPLANT,84,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37476.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,37476.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,37476.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,37476.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,37476.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,38600.52,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,37476.23,38600.52,
EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),91,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18582.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18582.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18582.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18582.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18582.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19140.13,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18582.65,19140.13,
EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),92,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19560.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19560.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19560.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,19560.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19560.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20147.21,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,19560.4,20147.21,
EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),93,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,32422.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,32422.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,32422.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,32422.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,32422.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,33395.16,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,32422.49,33395.16,
EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),94,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75232.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,75232.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,75232.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,75232.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,75232.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,77489.46,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,75232.49,77489.46,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,111,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22296.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22296.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22296.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,22296.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22296.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22965.56,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,22296.66,22965.56,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,112,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,48895.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,48895.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,48895.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,48895.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,48895.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,50362.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,48895.78,50362.65,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,113,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,56946.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,56946.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,56946.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,56946.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,56946.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,58654.42,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,56946.04,58654.42,
CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,114,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,97644.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,97644.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,97644.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,97644.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,97644.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,100573.5,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,97644.18,100573.5,
OPEN CRANIOTOMY FOR TRAUMA,201,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8402.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8402.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8402.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8402.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8402.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8654.25,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8402.18,8654.25,
OPEN CRANIOTOMY FOR TRAUMA,202,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9706.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9706.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9706.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9706.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9706.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9997.89,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9706.69,9997.89,
OPEN CRANIOTOMY FOR TRAUMA,203,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13885.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13885.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13885.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13885.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13885.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14302.06,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13885.49,14302.06,
OPEN CRANIOTOMY FOR TRAUMA,204,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22290.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22290.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22290.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,22290.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22290.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22959.64,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,22290.91,22959.64,
OPEN CRANIOTOMY EXCEPT TRAUMA,211,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7892.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7892.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7892.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7892.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7892.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8128.86,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7892.1,8128.86,
OPEN CRANIOTOMY EXCEPT TRAUMA,212,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10181.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10181.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10181.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10181.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10181.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10486.99,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10181.54,10486.99,
OPEN CRANIOTOMY EXCEPT TRAUMA,213,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15374.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15374.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15374.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15374.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15374.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15836.01,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15374.76,15836.01,
OPEN CRANIOTOMY EXCEPT TRAUMA,214,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24880.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24880.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24880.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,24880.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24880.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25627.29,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,24880.87,25627.29,
VENTRICULAR SHUNT PROCEDURES,221,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5197.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5197.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5197.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5197.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5197.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5353.09,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5197.17,5353.09,
VENTRICULAR SHUNT PROCEDURES,222,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6360.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6360.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6360.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6360.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6360.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6551.59,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6360.77,6551.59,
VENTRICULAR SHUNT PROCEDURES,223,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9814.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9814.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9814.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9814.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9814.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10109.33,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9814.89,10109.33,
VENTRICULAR SHUNT PROCEDURES,224,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19280.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19280.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19280.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,19280.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19280.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19859.15,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,19280.73,19859.15,
SPINAL PROCEDURES,231,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6782.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6782.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6782.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6782.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6782.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6985.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6782.06,6985.53,
SPINAL PROCEDURES,232,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8722.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8722.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8722.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8722.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8722.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8984.51,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8722.83,8984.51,
SPINAL PROCEDURES,233,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14468.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14468.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14468.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,14468.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14468.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14902.97,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,14468.91,14902.97,
SPINAL PROCEDURES,234,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22843.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22843.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22843.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,22843.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22843.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23528.34,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,22843.05,23528.34,
OPEN EXTRACRANIAL VASCULAR PROCEDURES,241,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3676.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3676.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3676.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3676.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3676.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3786.93,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3676.63,3786.93,
OPEN EXTRACRANIAL VASCULAR PROCEDURES,242,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4945.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4945.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4945.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4945.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4945.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5093.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4945.19,5093.54,
OPEN EXTRACRANIAL VASCULAR PROCEDURES,243,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8908.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8908.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8908.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8908.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8908.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9175.93,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8908.67,9175.93,
OPEN EXTRACRANIAL VASCULAR PROCEDURES,244,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16222.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16222.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16222.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16222.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16222.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16708.69,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16222.03,16708.69,
OTHER NERVOUS SYSTEM AND RELATED PROCEDURES,261,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5308.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5308.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5308.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5308.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5308.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5467.5,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5308.25,5467.5,
OTHER NERVOUS SYSTEM AND RELATED PROCEDURES,262,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6795,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6795,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6795,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6795,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6795,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6998.85,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6795,6998.85,
OTHER NERVOUS SYSTEM AND RELATED PROCEDURES,263,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10134.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10134.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10134.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10134.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10134.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10438.49,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10134.45,10438.49,
OTHER NERVOUS SYSTEM AND RELATED PROCEDURES,264,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18925.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18925.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18925.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18925.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18925.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19493.35,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18925.58,19493.35,
OTHER OPEN CRANIOTOMY,271,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7119.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7119.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7119.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7119.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7119.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7332.82,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7119.24,7332.82,
OTHER OPEN CRANIOTOMY,272,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8052.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8052.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8052.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8052.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8052.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8293.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8052.06,8293.62,
OTHER OPEN CRANIOTOMY,273,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13345.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13345.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13345.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13345.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13345.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13745.57,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13345.21,13745.57,
OTHER OPEN CRANIOTOMY,274,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23321.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23321.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23321.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,23321.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23321.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24021.52,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,23321.86,24021.52,
OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES,291,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8422.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8422.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8422.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8422.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8422.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8675.35,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8422.67,8675.35,
OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES,292,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9512.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9512.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9512.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9512.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9512.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9798.32,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9512.93,9798.32,
OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES,293,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10702.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10702.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10702.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10702.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10702.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11023.11,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10702.05,11023.11,
OTHER PERCUTANEOUS INTRACRANIAL PROCEDURES,294,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16368.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16368.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16368.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16368.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16368.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16859.38,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16368.33,16859.38,
PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES,301,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7287.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7287.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7287.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7287.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7287.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7506.47,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7287.83,7506.47,
PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES,302,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10061.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10061.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10061.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10061.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10061.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10363.33,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10061.48,10363.33,
PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES,303,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13662.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13662.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13662.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13662.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13662.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14072.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13662.98,14072.87,
PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES,304,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18347.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18347.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18347.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18347.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18347.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18897.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18347.2,18897.61,
SPINAL DISORDERS AND INJURIES,401,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4015.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4015.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4015.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4015.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4015.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4136.44,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4015.97,4136.44,
SPINAL DISORDERS AND INJURIES,402,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5406.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5406.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5406.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5406.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5406.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5568.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5406.38,5568.58,
SPINAL DISORDERS AND INJURIES,403,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7664.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7664.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7664.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7664.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7664.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7894.12,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7664.2,7894.12,
SPINAL DISORDERS AND INJURIES,404,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10858.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10858.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10858.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10858.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10858.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11184.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10858.78,11184.54,
NERVOUS SYSTEM MALIGNANCY,411,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3345.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3345.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3345.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3345.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3345.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3445.56,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3345.2,3445.56,
NERVOUS SYSTEM MALIGNANCY,412,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3434.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3434.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3434.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3434.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3434.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3537.38,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3434.35,3537.38,
NERVOUS SYSTEM MALIGNANCY,413,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4700.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4700.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4700.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4700.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4700.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4841.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4700.75,4841.77,
NERVOUS SYSTEM MALIGNANCY,414,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7270.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7270.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7270.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7270.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7270.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7489.07,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7270.94,7489.07,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,421,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2715.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2715.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2715.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2715.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2715.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2796.88,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2715.41,2796.88,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,422,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3423.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3423.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3423.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3423.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3423.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3525.9,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3423.2,3525.9,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,423,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5077.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5077.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5077.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5077.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5077.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5229.43,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5077.11,5229.43,
DEGENERATIVE NERVOUS SYSTEM DISORDERS EXCEPT MULTIPLE SCLEROSIS,424,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9661.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9661.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9661.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9661.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9661.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9951.24,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9661.39,9951.24,
"MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES",431,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3517.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3517.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3517.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3517.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3517.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3622.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3517.03,3622.54,
"MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES",432,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4869.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4869.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4869.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4869.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4869.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5015.79,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4869.7,5015.79,
"MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES",433,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7186.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7186.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7186.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7186.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7186.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7402.06,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7186.46,7402.06,
"MULTIPLE SCLEROSIS, OTHER DEMYELINATING DISEASE AND INFLAMMATORY NEUROPATHIES",434,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13693.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13693.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13693.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13693.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13693.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14103.97,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13693.18,14103.97,
INTRACRANIAL HEMORRHAGE,441,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3335.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3335.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3335.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3335.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3335.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3435.93,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3335.85,3435.93,
INTRACRANIAL HEMORRHAGE,442,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4472.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4472.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4472.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4472.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4472.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4607.03,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4472.85,4607.03,
INTRACRANIAL HEMORRHAGE,443,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6353.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6353.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6353.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6353.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6353.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6544.19,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6353.58,6544.19,
INTRACRANIAL HEMORRHAGE,444,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8091.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8091.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8091.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8091.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8091.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8334.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8091.96,8334.72,
CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,451,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2914.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2914.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2914.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2914.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2914.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3001.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2914.2,3001.62,
CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,452,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3754.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3754.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3754.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3754.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3754.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3867.27,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3754.63,3867.27,
CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,453,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5319.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5319.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5319.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5319.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5319.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5478.97,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5319.39,5478.97,
CVA AND PRECEREBRAL OCCLUSION WITH INFARCTION,454,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8879.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8879.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8879.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8879.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8879.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9145.94,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8879.55,9145.94,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION,461,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2978.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2978.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2978.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2978.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2978.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3067.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2978.18,3067.53,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION,462,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3418.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3418.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3418.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3418.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3418.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3520.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3418.17,3520.72,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION,463,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4435.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4435.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4435.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4435.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4435.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4568.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4435.46,4568.53,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION,464,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8827.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8827.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8827.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8827.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8827.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9092.25,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8827.43,9092.25,
TRANSIENT ISCHEMIA,471,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2733.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2733.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2733.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2733.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2733.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2815.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2733.03,2815.02,
TRANSIENT ISCHEMIA,472,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3062.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3062.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3062.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3062.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3062.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3154.17,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3062.3,3154.17,
TRANSIENT ISCHEMIA,473,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3867.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3867.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3867.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3867.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3867.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3983.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3867.51,3983.53,
TRANSIENT ISCHEMIA,474,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7029.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7029.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7029.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7029.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7029.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7240.26,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7029.38,7240.26,
"PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS",481,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2687.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2687.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2687.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2687.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2687.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2767.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2687.02,2767.63,
"PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS",482,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3024.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3024.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3024.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3024.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3024.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3114.92,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3024.2,3114.92,
"PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS",483,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4204.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4204.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4204.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4204.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4204.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4330.83,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4204.69,4330.83,
"PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DISORDERS",484,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8283.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8283.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8283.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8283.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8283.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8532.06,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8283.56,8532.06,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,491,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3727.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3727.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3727.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3727.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3727.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3839.5,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3727.67,3839.5,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,492,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7791.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7791.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7791.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7791.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7791.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8025.56,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7791.81,8025.56,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,493,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8874.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8874.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8874.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8874.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8874.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9141.13,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8874.88,9141.13,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,494,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14444.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14444.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14444.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,14444.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14444.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14877.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,14444.46,14877.8,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS,501,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2754.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2754.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2754.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2754.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2754.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2837.6,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2754.96,2837.6,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS,502,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5254.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5254.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5254.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5254.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5254.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5411.96,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5254.33,5411.96,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS,503,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8409.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8409.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8409.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8409.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8409.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8662.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8409.73,8662.02,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS,504,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16361.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16361.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16361.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16361.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16361.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16852.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16361.86,16852.72,
VIRAL MENINGITIS,511,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1994.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1994.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1994.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1994.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1994.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2054.52,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1994.68,2054.52,
VIRAL MENINGITIS,512,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2808.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2808.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2808.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2808.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2808.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2892.4,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2808.16,2892.4,
VIRAL MENINGITIS,513,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5009.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5009.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5009.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5009.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5009.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5159.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5009.17,5159.45,
VIRAL MENINGITIS,514,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9641.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9641.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9641.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9641.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9641.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9931.24,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9641.98,9931.24,
ALTERATION IN CONSCIOUSNESS,521,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2414.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2414.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2414.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2414.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2414.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2486.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2414.18,2486.61,
ALTERATION IN CONSCIOUSNESS,522,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2700.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2700.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2700.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2700.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2700.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2781.7,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2700.68,2781.7,
ALTERATION IN CONSCIOUSNESS,523,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3685.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3685.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3685.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3685.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3685.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3795.81,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3685.26,3795.81,
ALTERATION IN CONSCIOUSNESS,524,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8019.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8019.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8019.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8019.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8019.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8259.93,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8019.35,8259.93,
SEIZURE,531,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2168.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2168.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2168.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2168.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2168.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2233.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2168.66,2233.72,
SEIZURE,532,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2703.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2703.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2703.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2703.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2703.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2784.66,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2703.55,2784.66,
SEIZURE,533,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3870.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3870.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3870.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3870.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3870.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3986.86,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3870.74,3986.86,
SEIZURE,534,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8649.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8649.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8649.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8649.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8649.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8908.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8649.14,8908.61,
MIGRAINE AND OTHER HEADACHES,541,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2477.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2477.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2477.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2477.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2477.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2551.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2477.45,2551.77,
MIGRAINE AND OTHER HEADACHES,542,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2916.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2916.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2916.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2916.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2916.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3003.85,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2916.36,3003.85,
MIGRAINE AND OTHER HEADACHES,543,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3816.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3816.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3816.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3816.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3816.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3930.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3816.1,3930.58,
MIGRAINE AND OTHER HEADACHES,544,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6303.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6303.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6303.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6303.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6303.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6492.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6303.61,6492.72,
HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE,551,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2788.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2788.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2788.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2788.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2788.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2872.04,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2788.39,2872.04,
HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE,552,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3917.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3917.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3917.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3917.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3917.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4034.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3917.11,4034.63,
HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE,553,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6017.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6017.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6017.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6017.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6017.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6197.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6017.12,6197.63,
HEAD TRAUMA WITH COMA > 1 HOUR OR HEMORRHAGE,554,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11072.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11072.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11072.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11072.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11072.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11404.47,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11072.3,11404.47,
"BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA",561,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2811.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2811.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2811.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2811.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2811.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2896.1,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2811.75,2896.1,
"BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA",562,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3433.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3433.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3433.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3433.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3433.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3536.64,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3433.63,3536.64,
"BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA",563,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5495.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5495.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5495.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5495.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5495.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5660.4,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5495.53,5660.4,
"BRAIN CONTUSION OR LACERATION AND COMPLICATED SKULL FRACTURE, COMA < 1 HOUR OR NO COMA",564,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8904.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8904.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8904.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8904.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8904.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9171.86,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8904.72,9171.86,
"CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA",571,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2615.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2615.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2615.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2615.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2615.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2693.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2615.48,2693.95,
"CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA",572,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3640.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3640.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3640.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3640.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3640.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3749.9,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3640.68,3749.9,
"CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA",573,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5372.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5372.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5372.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5372.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5372.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5533.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5372.59,5533.77,
"CONCUSSION, CLOSED SKULL FRACTURE NOS, AND UNCOMPLICATED INTRACRANIAL INJURY, COMA < 1 HOUR OR NO COMA",574,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8554.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8554.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8554.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8554.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8554.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8811.6,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8554.96,8811.6,
OTHER DISORDERS OF NERVOUS SYSTEM,581,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3387.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3387.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3387.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3387.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3387.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3489.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3387.98,3489.62,
OTHER DISORDERS OF NERVOUS SYSTEM,582,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4538.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4538.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4538.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4538.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4538.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4674.79,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4538.63,4674.79,
OTHER DISORDERS OF NERVOUS SYSTEM,583,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5835.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5835.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5835.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5835.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5835.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6011.03,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5835.95,6011.03,
OTHER DISORDERS OF NERVOUS SYSTEM,584,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8363,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8363,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8363,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8363,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8363,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8613.89,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8363,8613.89,
ANOXIC AND OTHER SEVERE BRAIN DAMAGE,591,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2806,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2806,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2806,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2806,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2806,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2890.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2806,2890.18,
ANOXIC AND OTHER SEVERE BRAIN DAMAGE,592,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4116.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4116.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4116.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4116.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4116.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4240.48,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4116.98,4240.48,
ANOXIC AND OTHER SEVERE BRAIN DAMAGE,593,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6310.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6310.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6310.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6310.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6310.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6500.13,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6310.8,6500.13,
ANOXIC AND OTHER SEVERE BRAIN DAMAGE,594,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8531.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8531.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8531.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8531.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8531.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8787.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8531.59,8787.54,
ORBIT AND EYE PROCEDURES,731,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4021.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4021.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4021.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4021.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4021.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4142,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4021.36,4142,
ORBIT AND EYE PROCEDURES,732,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5076.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5076.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5076.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5076.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5076.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5228.31,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5076.03,5228.31,
ORBIT AND EYE PROCEDURES,733,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7873.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7873.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7873.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7873.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7873.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8109.24,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7873.05,8109.24,
ORBIT AND EYE PROCEDURES,734,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14167.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14167.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14167.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,14167.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14167.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14592.33,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,14167.31,14592.33,
EYE INFECTIONS AND OTHER EYE DISORDERS,821,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2373.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2373.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2373.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2373.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2373.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2444.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2373.56,2444.77,
EYE INFECTIONS AND OTHER EYE DISORDERS,822,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2915.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2915.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2915.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2915.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2915.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3003.11,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2915.64,3003.11,
EYE INFECTIONS AND OTHER EYE DISORDERS,823,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4432.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4432.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4432.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4432.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4432.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4565.94,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4432.95,4565.94,
EYE INFECTIONS AND OTHER EYE DISORDERS,824,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8891.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8891.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8891.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8891.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8891.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9158.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8891.78,9158.53,
MAJOR CRANIAL OR FACIAL BONE PROCEDURES,891,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6733.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6733.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6733.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6733.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6733.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6935.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6733.9,6935.91,
MAJOR CRANIAL OR FACIAL BONE PROCEDURES,892,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8626.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8626.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8626.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8626.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8626.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8885.28,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8626.49,8885.28,
MAJOR CRANIAL OR FACIAL BONE PROCEDURES,893,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15578.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15578.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15578.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15578.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15578.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16045.94,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15578.58,16045.94,
MAJOR CRANIAL OR FACIAL BONE PROCEDURES,894,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20717.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20717.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20717.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,20717.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20717.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21338.68,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,20717.16,21338.68,
OTHER MAJOR HEAD AND NECK PROCEDURES,911,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5942.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5942.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5942.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5942.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5942.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6120.99,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5942.71,6120.99,
OTHER MAJOR HEAD AND NECK PROCEDURES,912,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9176.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9176.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9176.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9176.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9176.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9451.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9176.47,9451.77,
OTHER MAJOR HEAD AND NECK PROCEDURES,913,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15819.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15819.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15819.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15819.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15819.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16294.01,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15819.42,16294.01,
OTHER MAJOR HEAD AND NECK PROCEDURES,914,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25293.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25293.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25293.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,25293.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25293.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26052.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,25293.9,26052.71,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES,921,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5503.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5503.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5503.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5503.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5503.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5668.17,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5503.08,5668.17,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES,922,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7227.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7227.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7227.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7227.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7227.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7444.27,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7227.44,7444.27,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES,923,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11220.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11220.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11220.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11220.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11220.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11557.39,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11220.76,11557.39,
FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIAL OR FACIAL BONE PROCEDURES,924,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21454.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21454.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21454.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,21454.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21454.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22098.06,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,21454.43,22098.06,
CLEFT LIP AND PALATE REPAIR,951,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3354.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3354.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3354.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3354.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3354.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3455.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3354.55,3455.18,
CLEFT LIP AND PALATE REPAIR,952,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3780.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3780.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3780.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3780.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3780.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3893.56,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3780.15,3893.56,
CLEFT LIP AND PALATE REPAIR,953,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6330.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6330.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6330.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6330.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6330.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6520.86,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6330.93,6520.86,
CLEFT LIP AND PALATE REPAIR,954,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11821.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11821.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11821.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11821.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11821.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12176.07,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11821.43,12176.07,
TONSIL AND ADENOID PROCEDURES,971,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2419.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2419.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2419.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2419.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2419.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2492.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2419.93,2492.53,
TONSIL AND ADENOID PROCEDURES,972,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3577.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3577.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3577.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3577.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3577.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3685.11,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3577.78,3685.11,
TONSIL AND ADENOID PROCEDURES,973,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5841.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5841.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5841.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5841.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5841.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6016.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5841.7,6016.95,
TONSIL AND ADENOID PROCEDURES,974,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10391.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10391.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10391.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10391.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10391.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10702.85,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10391.11,10702.85,
"OTHER EAR, NOSE, MOUTH, THROAT, CRANIOFACIAL, AND NECK PROCEDURES",981,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3556.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3556.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3556.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3556.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3556.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3663.26,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3556.57,3663.26,
"OTHER EAR, NOSE, MOUTH, THROAT, CRANIOFACIAL, AND NECK PROCEDURES",982,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4991.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4991.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4991.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4991.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4991.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5140.94,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4991.2,5140.94,
"OTHER EAR, NOSE, MOUTH, THROAT, CRANIOFACIAL, AND NECK PROCEDURES",983,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8351.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8351.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8351.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8351.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8351.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8601.67,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8351.14,8601.67,
"OTHER EAR, NOSE, MOUTH, THROAT, CRANIOFACIAL, AND NECK PROCEDURES",984,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15291.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15291.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15291.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15291.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15291.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15750.48,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15291.73,15750.48,
"EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES",1101,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3289.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3289.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3289.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3289.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3289.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3388.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3289.84,3388.54,
"EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES",1102,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3789.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3789.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3789.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3789.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3789.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3903.19,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3789.5,3903.19,
"EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES",1103,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5518.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5518.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5518.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5518.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5518.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5684.46,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5518.9,5684.46,
"EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL MALIGNANCIES",1104,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9528.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9528.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9528.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9528.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9528.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9814.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9528.75,9814.61,
VERTIGO AND OTHER LABYRINTH DISORDERS,1111,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2389.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2389.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2389.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2389.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2389.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2460.69,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2389.02,2460.69,
VERTIGO AND OTHER LABYRINTH DISORDERS,1112,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2649.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2649.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2649.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2649.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2649.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2729.49,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2649.99,2729.49,
VERTIGO AND OTHER LABYRINTH DISORDERS,1113,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3260.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3260.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3260.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3260.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3260.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3358.55,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3260.73,3358.55,
VERTIGO AND OTHER LABYRINTH DISORDERS,1114,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7039.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7039.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7039.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7039.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7039.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7250.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7039.44,7250.63,
INFECTIONS OF UPPER RESPIRATORY TRACT,1131,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1419.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1419.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1419.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1419.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1419.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1462.12,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1419.54,1462.12,
INFECTIONS OF UPPER RESPIRATORY TRACT,1132,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1974.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1974.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1974.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1974.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1974.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2034.16,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1974.91,2034.16,
INFECTIONS OF UPPER RESPIRATORY TRACT,1133,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2906.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2906.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2906.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2906.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2906.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2993.48,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2906.29,2993.48,
INFECTIONS OF UPPER RESPIRATORY TRACT,1134,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6186.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6186.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6186.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6186.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6186.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6372.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6186.43,6372.02,
DENTAL DISEASES AND DISORDERS,1141,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1663.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1663.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1663.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1663.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1663.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1713.15,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1663.25,1713.15,
DENTAL DISEASES AND DISORDERS,1142,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2351.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2351.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2351.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2351.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2351.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2422.55,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2351.99,2422.55,
DENTAL DISEASES AND DISORDERS,1143,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3522.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3522.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3522.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3522.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3522.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3627.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3522.06,3627.72,
DENTAL DISEASES AND DISORDERS,1144,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7231.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7231.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7231.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7231.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7231.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7448.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7231.76,7448.71,
"OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES",1151,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2063.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2063.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2063.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2063.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2063.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2125.24,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2063.34,2125.24,
"OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES",1152,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2820.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2820.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2820.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2820.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2820.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2904.99,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2820.38,2904.99,
"OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES",1153,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4420.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4420.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4420.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4420.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4420.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4552.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4420.01,4552.61,
"OTHER EAR, NOSE, MOUTH, THROAT AND CRANIAL OR FACIAL DIAGNOSES",1154,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7823.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7823.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7823.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7823.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7823.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8058.14,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7823.44,8058.14,
MAJOR RESPIRATORY AND CHEST PROCEDURES,1201,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6700.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6700.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6700.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6700.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6700.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6901.85,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6700.82,6901.85,
MAJOR RESPIRATORY AND CHEST PROCEDURES,1202,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8374.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8374.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8374.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8374.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8374.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8625.74,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8374.5,8625.74,
MAJOR RESPIRATORY AND CHEST PROCEDURES,1203,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12619.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12619.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12619.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12619.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12619.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12998.4,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12619.81,12998.4,
MAJOR RESPIRATORY AND CHEST PROCEDURES,1204,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23868.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23868.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23868.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,23868.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23868.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24584.67,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,23868.61,24584.67,
OTHER RESPIRATORY AND CHEST PROCEDURES,1211,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5197.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5197.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5197.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5197.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5197.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5353.46,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5197.53,5353.46,
OTHER RESPIRATORY AND CHEST PROCEDURES,1212,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6781.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6781.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6781.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6781.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6781.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6985.16,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6781.7,6985.16,
OTHER RESPIRATORY AND CHEST PROCEDURES,1213,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10780.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10780.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10780.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10780.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10780.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11104.2,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10780.77,11104.2,
OTHER RESPIRATORY AND CHEST PROCEDURES,1214,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18918.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18918.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18918.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18918.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18918.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19485.57,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18918.03,19485.57,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS,1301,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11364.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11364.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11364.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11364.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11364.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11705.86,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11364.91,11705.86,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS,1302,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12648.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12648.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12648.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12648.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12648.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13028.39,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12648.92,13028.39,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS,1303,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15341.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15341.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15341.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15341.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15341.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15801.57,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15341.33,15801.57,
RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT > 96 HOURS,1304,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20109.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20109.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20109.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,20109.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20109.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20712.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,20109.66,20712.95,
CYSTIC FIBROSIS - PULMONARY DISEASE,1311,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4983.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4983.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4983.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4983.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4983.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5133.16,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4983.65,5133.16,
CYSTIC FIBROSIS - PULMONARY DISEASE,1312,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6445.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6445.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6445.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6445.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6445.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6638.6,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6445.24,6638.6,
CYSTIC FIBROSIS - PULMONARY DISEASE,1313,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8737.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8737.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8737.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8737.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8737.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9000.06,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8737.92,9000.06,
CYSTIC FIBROSIS - PULMONARY DISEASE,1314,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11459.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11459.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11459.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11459.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11459.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11803.23,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11459.45,11803.23,
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,1321,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1542.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1542.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1542.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1542.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1542.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1588.75,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1542.47,1588.75,
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,1322,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2378.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2378.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2378.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2378.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2378.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2449.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2378.59,2449.95,
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,1323,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4473.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4473.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4473.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4473.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4473.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4607.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4473.57,4607.77,
BPD AND OTHER CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,1324,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6637.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6637.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6637.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6637.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6637.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6836.31,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6637.2,6836.31,
RESPIRATORY FAILURE,1331,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1584.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1584.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1584.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1584.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1584.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1631.7,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1584.17,1631.7,
RESPIRATORY FAILURE,1332,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2731.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2731.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2731.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2731.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2731.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2813.17,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2731.23,2813.17,
RESPIRATORY FAILURE,1333,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4210.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4210.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4210.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4210.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4210.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4336.75,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4210.44,4336.75,
RESPIRATORY FAILURE,1334,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7236.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7236.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7236.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7236.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7236.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7453.52,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7236.43,7453.52,
PULMONARY EMBOLISM,1341,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2129.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2129.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2129.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2129.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2129.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2193.37,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2129.48,2193.37,
PULMONARY EMBOLISM,1342,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2794.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2794.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2794.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2794.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2794.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2877.96,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2794.14,2877.96,
PULMONARY EMBOLISM,1343,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4312.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4312.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4312.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4312.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4312.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4441.9,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4312.53,4441.9,
PULMONARY EMBOLISM,1344,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7245.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7245.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7245.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7245.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7245.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7462.78,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7245.42,7462.78,
MAJOR CHEST AND RESPIRATORY TRAUMA,1351,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2902.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2902.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2902.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2902.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2902.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2989.78,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2902.7,2989.78,
MAJOR CHEST AND RESPIRATORY TRAUMA,1352,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3339.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3339.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3339.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3339.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3339.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3439.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3339.45,3439.63,
MAJOR CHEST AND RESPIRATORY TRAUMA,1353,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4794.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4794.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4794.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4794.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4794.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4938.04,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4794.21,4938.04,
MAJOR CHEST AND RESPIRATORY TRAUMA,1354,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8378.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8378.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8378.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8378.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8378.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8630.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8378.82,8630.18,
RESPIRATORY MALIGNANCY,1361,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2843.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2843.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2843.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2843.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2843.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2928.32,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2843.02,2928.32,
RESPIRATORY MALIGNANCY,1362,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3619.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3619.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3619.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3619.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3619.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3727.69,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3619.11,3727.69,
RESPIRATORY MALIGNANCY,1363,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5172.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5172.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5172.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5172.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5172.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5327.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5172.37,5327.54,
RESPIRATORY MALIGNANCY,1364,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7917.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7917.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7917.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7917.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7917.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8155.15,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7917.62,8155.15,
MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,1371,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2274.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2274.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2274.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2274.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2274.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2342.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2274.71,2342.95,
MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,1372,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2912.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2912.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2912.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2912.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2912.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2999.4,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2912.04,2999.4,
MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,1373,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3889.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3889.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3889.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3889.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3889.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4006.49,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3889.79,4006.49,
MAJOR RESPIRATORY INFECTIONS AND INFLAMMATIONS,1374,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7331.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7331.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7331.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7331.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7331.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7551.64,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7331.69,7551.64,
BRONCHIOLITIS AND RSV PNEUMONIA,1381,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1273.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1273.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1273.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1273.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1273.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1311.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1273.59,1311.8,
BRONCHIOLITIS AND RSV PNEUMONIA,1382,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1849.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1849.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1849.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1849.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1849.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1905.31,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1849.82,1905.31,
BRONCHIOLITIS AND RSV PNEUMONIA,1383,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3068.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3068.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3068.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3068.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3068.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3160.09,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3068.05,3160.09,
BRONCHIOLITIS AND RSV PNEUMONIA,1384,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7558.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7558.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7558.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7558.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7558.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7784.9,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7558.15,7784.9,
OTHER PNEUMONIA,1391,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1738.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1738.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1738.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1738.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1738.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1790.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1738.38,1790.53,
OTHER PNEUMONIA,1392,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2280.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2280.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2280.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2280.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2280.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2348.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2280.46,2348.87,
OTHER PNEUMONIA,1393,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3429.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3429.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3429.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3429.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3429.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3532.19,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3429.32,3532.19,
OTHER PNEUMONIA,1394,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6230.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6230.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6230.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6230.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6230.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6417.56,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6230.64,6417.56,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,1401,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1933.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1933.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1933.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1933.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1933.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1991.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1933.93,1991.95,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,1402,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2432.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2432.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2432.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2432.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2432.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2505.12,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2432.15,2505.12,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,1403,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3054.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3054.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3054.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3054.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3054.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3145.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3054.03,3145.65,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,1404,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5937.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5937.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5937.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5937.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5937.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6115.44,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5937.32,6115.44,
ASTHMA,1411,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1689.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1689.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1689.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1689.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1689.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1740.55,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1689.85,1740.55,
ASTHMA,1412,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2421.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2421.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2421.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2421.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2421.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2494.38,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2421.73,2494.38,
ASTHMA,1413,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2792.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2792.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2792.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2792.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2792.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2876.48,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2792.7,2876.48,
ASTHMA,1414,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5664.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5664.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5664.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5664.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5664.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5834.79,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5664.84,5834.79,
INTERSTITIAL AND ALVEOLAR LUNG DISEASES,1421,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2518.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2518.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2518.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2518.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2518.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2593.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2518.07,2593.61,
INTERSTITIAL AND ALVEOLAR LUNG DISEASES,1422,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2986.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2986.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2986.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2986.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2986.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3075.68,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2986.09,3075.68,
INTERSTITIAL AND ALVEOLAR LUNG DISEASES,1423,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4532.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4532.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4532.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4532.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4532.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4668.12,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4532.16,4668.12,
INTERSTITIAL AND ALVEOLAR LUNG DISEASES,1424,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8096.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8096.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8096.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8096.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8096.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8339.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8096.63,8339.53,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",1431,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2087.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2087.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2087.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2087.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2087.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2150.42,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2087.78,2150.42,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",1432,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2981.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2981.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2981.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2981.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2981.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3070.86,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2981.42,3070.86,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",1433,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4621.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4621.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4621.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4621.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4621.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4759.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4621.31,4759.95,
"OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",1434,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7721.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7721.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7721.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7721.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7721.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7953.36,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7721.71,7953.36,
"RESPIRATORY SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",1441,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2123.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2123.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2123.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2123.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2123.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2187.44,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2123.73,2187.44,
"RESPIRATORY SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",1442,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2771.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2771.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2771.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2771.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2771.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2855.01,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2771.85,2855.01,
"RESPIRATORY SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",1443,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4199.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4199.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4199.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4199.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4199.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4325.64,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4199.65,4325.64,
"RESPIRATORY SIGNS, SYMPTOMS AND MISCELLANEOUS DIAGNOSES",1444,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7624.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7624.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7624.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7624.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7624.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7853.39,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7624.65,7853.39,
ACUTE BRONCHITIS AND RELATED SYMPTOMS,1451,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1979.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1979.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1979.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1979.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1979.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2038.97,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1979.58,2038.97,
ACUTE BRONCHITIS AND RELATED SYMPTOMS,1452,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2459.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2459.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2459.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2459.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2459.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2533.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2459.83,2533.63,
ACUTE BRONCHITIS AND RELATED SYMPTOMS,1453,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3206.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3206.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3206.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3206.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3206.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3302.27,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3206.09,3302.27,
ACUTE BRONCHITIS AND RELATED SYMPTOMS,1454,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5770.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5770.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5770.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5770.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5770.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5943.64,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5770.52,5943.64,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,1601,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11060.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11060.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11060.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11060.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11060.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11392.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11060.8,11392.62,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,1602,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14065.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14065.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14065.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,14065.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14065.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14487.92,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,14065.94,14487.92,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,1603,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22487.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22487.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22487.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,22487.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22487.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23162.16,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,22487.54,23162.16,
MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,1604,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,55523.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,55523.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,55523.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,55523.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,55523.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,57189.34,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,55523.63,57189.34,
IMPLANTABLE HEART ASSIST SYSTEMS,1611,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,49247.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,49247.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,49247.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,49247.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,49247.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,50724.76,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,49247.34,50724.76,
IMPLANTABLE HEART ASSIST SYSTEMS,1612,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51688.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,51688.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,51688.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,51688.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,51688.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,53239.5,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,51688.84,53239.5,
IMPLANTABLE HEART ASSIST SYSTEMS,1613,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,64392.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,64392.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,64392.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,64392.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,64392.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,66324.17,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,64392.4,66324.17,
IMPLANTABLE HEART ASSIST SYSTEMS,1614,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,95167.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,95167.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,95167.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,95167.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,95167.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,98022.1,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,95167.09,98022.1,
CARDIAC VALVE PROCEDURES WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,1621,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15492.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15492.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15492.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15492.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15492.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15957.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15492.67,15957.45,
CARDIAC VALVE PROCEDURES WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,1622,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18011.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18011.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18011.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18011.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18011.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18551.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18011.45,18551.8,
CARDIAC VALVE PROCEDURES WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,1623,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24215.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24215.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24215.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,24215.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24215.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24941.96,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,24215.49,24941.96,
CARDIAC VALVE PROCEDURES WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,1624,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37904.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,37904.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,37904.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,37904.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,37904.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,39041.86,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,37904.72,39041.86,
CARDIAC VALVE PROCEDURES WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,1631,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13274.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13274.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13274.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13274.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13274.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13673,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13274.76,13673,
CARDIAC VALVE PROCEDURES WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,1632,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15129.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15129.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15129.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15129.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15129.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15583.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15129.97,15583.87,
CARDIAC VALVE PROCEDURES WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,1633,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20149.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20149.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20149.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,20149.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20149.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20754.05,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,20149.56,20754.05,
CARDIAC VALVE PROCEDURES WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,1634,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31574.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,31574.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,31574.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,31574.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,31574.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,32521.74,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,31574.5,32521.74,
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,1651,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13750.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13750.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13750.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13750.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13750.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14162.84,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13750.33,14162.84,
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,1652,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15429.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15429.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15429.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15429.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15429.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15892.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15429.76,15892.65,
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,1653,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19734.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19734.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19734.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,19734.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19734.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20326.04,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,19734.02,20326.04,
CORONARY BYPASS WITH AMI OR COMPLEX PRINCIPAL DIAGNOSIS,1654,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29487.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29487.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29487.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,29487.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29487.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30372.06,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,29487.44,30372.06,
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,1661,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11418.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11418.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11418.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11418.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11418.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11761.39,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11418.83,11761.39,
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,1662,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13175.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13175.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13175.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13175.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13175.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13571.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13175.9,13571.18,
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,1663,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16587.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16587.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16587.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16587.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16587.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17085.6,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16587.96,17085.6,
CORONARY BYPASS WITHOUT AMI OR COMPLEX PRINCIPAL DIAGNOSIS,1664,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25822.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25822.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25822.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,25822.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25822.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26597.35,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,25822.67,26597.35,
OTHER CARDIOTHORACIC AND THORACIC VASCULAR PROCEDURES,1671,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11415.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11415.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11415.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11415.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11415.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11757.69,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11415.23,11757.69,
OTHER CARDIOTHORACIC AND THORACIC VASCULAR PROCEDURES,1672,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11819.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11819.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11819.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11819.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11819.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12174.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11819.63,12174.22,
OTHER CARDIOTHORACIC AND THORACIC VASCULAR PROCEDURES,1673,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18266.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18266.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18266.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18266.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18266.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18814.68,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18266.68,18814.68,
OTHER CARDIOTHORACIC AND THORACIC VASCULAR PROCEDURES,1674,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31789.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,31789.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,31789.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,31789.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,31789.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,32742.78,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,31789.1,32742.78,
MAJOR ABDOMINAL VASCULAR PROCEDURES,1691,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10402.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10402.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10402.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10402.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10402.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10715.06,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10402.97,10715.06,
MAJOR ABDOMINAL VASCULAR PROCEDURES,1692,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10587.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10587.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10587.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10587.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10587.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10904.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10587.02,10904.63,
MAJOR ABDOMINAL VASCULAR PROCEDURES,1693,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14371.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14371.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14371.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,14371.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14371.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14803.01,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,14371.85,14803.01,
MAJOR ABDOMINAL VASCULAR PROCEDURES,1694,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22756.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22756.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22756.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,22756.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22756.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23439.48,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,22756.78,23439.48,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK",1701,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7687.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7687.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7687.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7687.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7687.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7918.56,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7687.92,7918.56,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK",1702,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8112.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8112.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8112.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8112.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8112.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8355.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8112.09,8355.45,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK",1703,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11741.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11741.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11741.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11741.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11741.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12093.51,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11741.27,12093.51,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITH AMI, HEART FAILURE OR SHOCK",1704,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16690.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16690.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16690.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16690.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16690.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17191.12,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16690.41,17191.12,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK",1711,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5822.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5822.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5822.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5822.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5822.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5997.33,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5822.65,5997.33,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK",1712,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6686.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6686.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6686.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6686.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6686.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6886.67,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6686.09,6886.67,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK",1713,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8975.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8975.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8975.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8975.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8975.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9245.17,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8975.89,9245.17,
"PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT AMI, HEART FAILURE OR SHOCK",1714,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14391.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14391.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14391.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,14391.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14391.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14823,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,14391.26,14823,
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,1741,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6846.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6846.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6846.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6846.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6846.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7051.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6846.41,7051.8,
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,1742,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7586.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7586.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7586.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7586.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7586.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7814.52,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7586.91,7814.52,
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,1743,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9801.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9801.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9801.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9801.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9801.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10095.26,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9801.23,10095.26,
PERCUTANEOUS CARDIAC INTERVENTION WITH AMI,1744,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14611.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14611.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14611.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,14611.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14611.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15050.33,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,14611.97,15050.33,
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI,1751,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8032.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8032.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8032.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8032.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8032.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8273.26,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8032.29,8273.26,
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI,1752,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8843.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8843.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8843.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8843.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8843.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9109.29,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8843.97,9109.29,
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI,1753,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11099.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11099.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11099.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11099.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11099.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11432.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11099.62,11432.61,
PERCUTANEOUS CARDIAC INTERVENTION WITHOUT AMI,1754,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16451.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16451.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16451.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16451.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16451.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16945.28,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16451.73,16945.28,
"INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES",1761,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6297.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6297.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6297.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6297.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6297.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6486.06,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6297.14,6486.06,
"INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES",1762,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7842.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7842.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7842.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7842.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7842.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8078.14,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7842.85,8078.14,
"INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES",1763,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11861.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11861.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11861.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11861.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11861.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12217.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11861.69,12217.54,
"INSERTION, REVISION AND REPLACEMENTS OF PACEMAKER AND OTHER CARDIAC DEVICES",1764,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20371.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20371.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20371.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,20371.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20371.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20982.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,20371.71,20982.87,
CARDIAC PACEMAKER AND DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,1771,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5062.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5062.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5062.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5062.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5062.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5214.24,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5062.37,5214.24,
CARDIAC PACEMAKER AND DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,1772,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6824.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6824.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6824.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6824.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6824.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7029.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6824.48,7029.22,
CARDIAC PACEMAKER AND DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,1773,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10130.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10130.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10130.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10130.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10130.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10434.41,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10130.5,10434.41,
CARDIAC PACEMAKER AND DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,1774,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13064.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13064.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13064.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13064.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13064.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13456.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13064.83,13456.77,
EXTERNAL HEART ASSIST SYSTEMS,1781,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18176.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18176.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18176.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18176.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18176.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18721.74,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18176.45,18721.74,
EXTERNAL HEART ASSIST SYSTEMS,1782,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21425.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21425.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21425.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,21425.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21425.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22068.07,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,21425.31,22068.07,
EXTERNAL HEART ASSIST SYSTEMS,1783,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22287.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22287.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22287.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,22287.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22287.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22956.3,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,22287.67,22956.3,
EXTERNAL HEART ASSIST SYSTEMS,1784,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30258.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30258.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30258.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,30258.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30258.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,31165.88,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,30258.13,31165.88,
DEFIBRILLATOR IMPLANTS,1791,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12711.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12711.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12711.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12711.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12711.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13093.19,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12711.83,13093.19,
DEFIBRILLATOR IMPLANTS,1792,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14465.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14465.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14465.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,14465.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14465.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14899.27,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,14465.31,14899.27,
DEFIBRILLATOR IMPLANTS,1793,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17747.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17747.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17747.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,17747.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17747.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18280.4,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,17747.96,18280.4,
DEFIBRILLATOR IMPLANTS,1794,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24521.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24521.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24521.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,24521.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24521.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25257.41,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,24521.76,25257.41,
OTHER CIRCULATORY SYSTEM PROCEDURES,1801,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4736.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4736.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4736.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4736.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4736.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4878.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4736.7,4878.8,
OTHER CIRCULATORY SYSTEM PROCEDURES,1802,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6030.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6030.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6030.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6030.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6030.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6211.33,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6030.42,6211.33,
OTHER CIRCULATORY SYSTEM PROCEDURES,1803,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8454.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8454.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8454.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8454.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8454.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8708.3,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8454.66,8708.3,
OTHER CIRCULATORY SYSTEM PROCEDURES,1804,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14683.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14683.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14683.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,14683.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14683.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15124.01,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,14683.51,15124.01,
LOWER EXTREMITY ARTERIAL PROCEDURES,1811,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5524.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5524.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5524.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5524.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5524.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5690.39,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5524.65,5690.39,
LOWER EXTREMITY ARTERIAL PROCEDURES,1812,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8026.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8026.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8026.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8026.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8026.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8267.33,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8026.54,8267.33,
LOWER EXTREMITY ARTERIAL PROCEDURES,1813,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12668.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12668.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12668.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12668.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12668.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13048.76,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12668.7,13048.76,
LOWER EXTREMITY ARTERIAL PROCEDURES,1814,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19809.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19809.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19809.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,19809.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19809.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20404.16,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,19809.87,20404.16,
OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES,1821,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7407.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7407.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7407.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7407.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7407.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7630.13,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7407.9,7630.13,
OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES,1822,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8311.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8311.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8311.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8311.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8311.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8560.57,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8311.24,8560.57,
OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES,1823,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10180.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10180.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10180.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10180.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10180.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10486.25,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10180.82,10486.25,
OTHER PERIPHERAL VASCULAR AND RELATED PROCEDURES,1824,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18084.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18084.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18084.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18084.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18084.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18626.96,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18084.43,18626.96,
PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES,1831,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13865,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13865,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13865,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13865,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13865,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14280.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13865,14280.95,
PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES,1832,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14539.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14539.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14539.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,14539.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14539.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14975.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,14539.36,14975.54,
PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES,1833,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17659.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17659.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17659.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,17659.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17659.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18189.69,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,17659.89,18189.69,
PERCUTANEOUS STRUCTURAL CARDIAC PROCEDURES,1834,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26369.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26369.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26369.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,26369.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26369.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,27160.13,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,26369.06,27160.13,
ACUTE MYOCARDIAL INFARCTION,1901,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2996.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2996.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2996.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2996.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2996.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3086.04,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2996.16,3086.04,
ACUTE MYOCARDIAL INFARCTION,1902,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3322.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3322.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3322.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3322.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3322.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3422.6,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3322.91,3422.6,
ACUTE MYOCARDIAL INFARCTION,1903,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4521.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4521.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4521.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4521.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4521.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4656.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4521.02,4656.65,
ACUTE MYOCARDIAL INFARCTION,1904,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7680.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7680.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7680.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7680.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7680.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7910.78,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7680.37,7910.78,
CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,1911,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3626.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3626.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3626.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3626.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3626.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3735.46,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3626.66,3735.46,
CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,1912,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4129.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4129.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4129.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4129.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4129.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4253.44,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4129.56,4253.44,
CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,1913,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5670.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5670.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5670.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5670.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5670.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5841.08,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5670.95,5841.08,
CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,1914,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10273.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10273.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10273.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10273.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10273.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10581.4,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10273.21,10581.4,
CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,1921,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3840.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3840.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3840.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3840.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3840.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3955.39,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3840.19,3955.39,
CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,1922,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4681.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4681.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4681.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4681.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4681.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4822.15,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4681.7,4822.15,
CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,1923,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6891.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6891.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6891.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6891.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6891.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7098.08,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6891.34,7098.08,
CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,1924,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12284.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12284.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12284.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12284.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12284.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12652.96,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12284.43,12652.96,
ACUTE AND SUBACUTE ENDOCARDITIS,1931,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3512.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3512.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3512.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3512.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3512.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3617.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3512.35,3617.72,
ACUTE AND SUBACUTE ENDOCARDITIS,1932,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4165.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4165.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4165.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4165.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4165.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4290.1,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4165.14,4290.1,
ACUTE AND SUBACUTE ENDOCARDITIS,1933,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5869.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5869.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5869.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5869.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5869.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6045.83,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5869.74,6045.83,
ACUTE AND SUBACUTE ENDOCARDITIS,1934,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9214.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9214.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9214.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9214.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9214.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9491.38,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9214.94,9491.38,
HEART FAILURE,1941,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1926.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1926.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1926.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1926.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1926.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1984.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1926.38,1984.18,
HEART FAILURE,1942,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2573.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2573.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2573.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2573.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2573.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2650.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2573.42,2650.63,
HEART FAILURE,1943,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3816.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3816.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3816.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3816.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3816.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3930.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3816.46,3930.95,
HEART FAILURE,1944,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7156.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7156.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7156.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7156.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7156.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7371.7,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7156.99,7371.7,
CARDIAC ARREST AND SHOCK,1961,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1695.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1695.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1695.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1695.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1695.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1746.47,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1695.61,1746.47,
CARDIAC ARREST AND SHOCK,1962,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2178.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2178.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2178.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2178.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2178.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2243.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2178.37,2243.72,
CARDIAC ARREST AND SHOCK,1963,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3694.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3694.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3694.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3694.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3694.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3805.81,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3694.96,3805.81,
CARDIAC ARREST AND SHOCK,1964,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7362.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7362.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7362.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7362.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7362.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7583.11,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7362.24,7583.11,
PERIPHERAL AND OTHER VASCULAR DISORDERS,1971,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2182.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2182.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2182.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2182.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2182.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2248.16,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2182.68,2248.16,
PERIPHERAL AND OTHER VASCULAR DISORDERS,1972,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2759.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2759.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2759.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2759.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2759.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2842.42,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2759.63,2842.42,
PERIPHERAL AND OTHER VASCULAR DISORDERS,1973,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3957.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3957.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3957.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3957.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3957.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4075.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3957.01,4075.72,
PERIPHERAL AND OTHER VASCULAR DISORDERS,1974,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7485.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7485.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7485.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7485.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7485.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7710.48,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7485.9,7710.48,
ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,1981,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2075.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2075.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2075.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2075.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2075.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2138.2,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2075.92,2138.2,
ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,1982,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2383.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2383.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2383.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2383.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2383.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2454.76,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2383.27,2454.76,
ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,1983,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3175.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3175.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3175.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3175.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3175.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3271.17,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3175.89,3271.17,
ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,1984,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6369.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6369.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6369.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6369.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6369.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6560.48,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6369.4,6560.48,
HYPERTENSION,1991,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2103.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2103.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2103.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2103.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2103.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2167.08,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2103.96,2167.08,
HYPERTENSION,1992,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2473.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2473.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2473.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2473.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2473.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2548.07,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2473.85,2548.07,
HYPERTENSION,1993,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3500.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3500.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3500.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3500.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3500.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3605.5,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3500.49,3605.5,
HYPERTENSION,1994,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6375.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6375.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6375.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6375.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6375.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6567.14,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6375.87,6567.14,
CARDIAC STRUCTURAL AND VALVULAR DISORDERS,2001,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2340.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2340.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2340.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2340.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2340.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2410.7,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2340.49,2410.7,
CARDIAC STRUCTURAL AND VALVULAR DISORDERS,2002,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3046.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3046.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3046.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3046.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3046.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3137.51,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3046.12,3137.51,
CARDIAC STRUCTURAL AND VALVULAR DISORDERS,2003,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4427.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4427.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4427.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4427.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4427.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4560.75,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4427.91,4560.75,
CARDIAC STRUCTURAL AND VALVULAR DISORDERS,2004,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7961.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7961.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7961.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7961.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7961.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8200.69,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7961.83,8200.69,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,2011,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1722.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1722.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1722.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1722.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1722.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1773.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1722.21,1773.87,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,2012,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2216.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2216.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2216.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2216.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2216.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2282.6,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2216.11,2282.6,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,2013,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3425.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3425.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3425.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3425.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3425.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3528.12,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3425.36,3528.12,
CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS,2014,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6639.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6639.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6639.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6639.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6639.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6838.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6639.36,6838.54,
CHEST PAIN,2031,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2206.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2206.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2206.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2206.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2206.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2272.6,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2206.41,2272.6,
CHEST PAIN,2032,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2460.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2460.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2460.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2460.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2460.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2534,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2460.19,2534,
CHEST PAIN,2033,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3061.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3061.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3061.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3061.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3061.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3153.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3061.94,3153.8,
CHEST PAIN,2034,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5278.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5278.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5278.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5278.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5278.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5436.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5278.41,5436.77,
SYNCOPE AND COLLAPSE,2041,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2449.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2449.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2449.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2449.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2449.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2522.89,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2449.41,2522.89,
SYNCOPE AND COLLAPSE,2042,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2698.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2698.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2698.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2698.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2698.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2779.47,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2698.52,2779.47,
SYNCOPE AND COLLAPSE,2043,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3401.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3401.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3401.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3401.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3401.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3503.69,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3401.64,3503.69,
SYNCOPE AND COLLAPSE,2044,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6168.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6168.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6168.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6168.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6168.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6353.14,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6168.09,6353.14,
CARDIOMYOPATHY,2051,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2294.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2294.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2294.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2294.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2294.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2362.94,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2294.12,2362.94,
CARDIOMYOPATHY,2052,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2424.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2424.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2424.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2424.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2424.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2497.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2424.96,2497.71,
CARDIOMYOPATHY,2053,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4031.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4031.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4031.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4031.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4031.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4152.37,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4031.42,4152.37,
CARDIOMYOPATHY,2054,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8711.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8711.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8711.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8711.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8711.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8972.66,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8711.32,8972.66,
"MALFUNCTION, REACTION, COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE",2061,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2894.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2894.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2894.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2894.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2894.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2980.89,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2894.07,2980.89,
"MALFUNCTION, REACTION, COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE",2062,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3046.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3046.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3046.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3046.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3046.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3138.25,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3046.84,3138.25,
"MALFUNCTION, REACTION, COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE",2063,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4417.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4417.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4417.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4417.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4417.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4549.64,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4417.13,4549.64,
"MALFUNCTION, REACTION, COMPLICATION OF CARDIAC OR VASCULAR DEVICE OR PROCEDURE",2064,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8478.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8478.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8478.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8478.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8478.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8732.74,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8478.39,8732.74,
OTHER CIRCULATORY SYSTEM DIAGNOSES,2071,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2138.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2138.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2138.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2138.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2138.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2202.25,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2138.11,2202.25,
OTHER CIRCULATORY SYSTEM DIAGNOSES,2072,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2742.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2742.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2742.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2742.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2742.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2824.64,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2742.37,2824.64,
OTHER CIRCULATORY SYSTEM DIAGNOSES,2073,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3999.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3999.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3999.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3999.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3999.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4119.78,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3999.79,4119.78,
OTHER CIRCULATORY SYSTEM DIAGNOSES,2074,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7439.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7439.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7439.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7439.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7439.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7662.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7439.53,7662.71,
"MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",2201,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5614.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5614.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5614.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5614.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5614.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5783.32,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5614.87,5783.32,
"MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",2202,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7877.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7877.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7877.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7877.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7877.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8113.68,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7877.36,8113.68,
"MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",2203,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12105.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12105.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12105.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12105.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12105.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12468.94,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12105.77,12468.94,
"MAJOR STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",2204,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22906.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22906.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22906.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,22906.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22906.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23593.51,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,22906.32,23593.51,
"OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",2221,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3057.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3057.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3057.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3057.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3057.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3149.36,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3057.63,3149.36,
"OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",2222,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5362.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5362.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5362.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5362.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5362.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5523.03,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5362.17,5523.03,
"OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",2223,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8120.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8120.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8120.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8120.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8120.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8363.97,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8120.36,8363.97,
"OTHER STOMACH, ESOPHAGEAL AND DUODENAL PROCEDURES",2224,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15715.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15715.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15715.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15715.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15715.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16187,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15715.54,16187,
OTHER SMALL AND LARGE BOWEL PROCEDURES,2231,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4287.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4287.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4287.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4287.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4287.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4415.98,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4287.36,4415.98,
OTHER SMALL AND LARGE BOWEL PROCEDURES,2232,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5470.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5470.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5470.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5470.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5470.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5634.11,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5470.01,5634.11,
OTHER SMALL AND LARGE BOWEL PROCEDURES,2233,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7738.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7738.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7738.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7738.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7738.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7970.76,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7738.61,7970.76,
OTHER SMALL AND LARGE BOWEL PROCEDURES,2234,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15587.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15587.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15587.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15587.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15587.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16054.82,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15587.21,16054.82,
PERITONEAL ADHESIOLYSIS,2241,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5094.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5094.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5094.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5094.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5094.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5247.57,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5094.73,5247.57,
PERITONEAL ADHESIOLYSIS,2242,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5936.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5936.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5936.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5936.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5936.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6115.07,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5936.96,6115.07,
PERITONEAL ADHESIOLYSIS,2243,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8625.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8625.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8625.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8625.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8625.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8884.17,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8625.41,8884.17,
PERITONEAL ADHESIOLYSIS,2244,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15077.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15077.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15077.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15077.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15077.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15529.81,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15077.48,15529.81,
ANAL AND PERINEAL PROCEDURES,2261,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3130.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3130.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3130.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3130.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3130.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3224.89,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3130.96,3224.89,
ANAL AND PERINEAL PROCEDURES,2262,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3947.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3947.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3947.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3947.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3947.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4066.1,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3947.67,4066.1,
ANAL AND PERINEAL PROCEDURES,2263,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6039.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6039.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6039.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6039.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6039.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6220.96,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6039.76,6220.96,
ANAL AND PERINEAL PROCEDURES,2264,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11482.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11482.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11482.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11482.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11482.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11826.56,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11482.09,11826.56,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL",2271,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4380.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4380.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4380.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4380.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4380.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4512.25,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4380.82,4512.25,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL",2272,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5349.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5349.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5349.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5349.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5349.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5510.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5349.95,5510.45,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL",2273,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7840.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7840.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7840.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7840.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7840.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8075.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7840.33,8075.54,
"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL AND UMBILICAL",2274,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15313.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15313.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15313.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15313.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15313.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15772.69,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15313.29,15772.69,
"INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES",2281,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3679.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3679.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3679.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3679.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3679.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3789.52,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3679.14,3789.52,
"INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES",2282,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4579.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4579.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4579.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4579.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4579.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4716.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4579.25,4716.63,
"INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES",2283,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6383.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6383.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6383.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6383.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6383.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6575.29,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6383.77,6575.29,
"INGUINAL, FEMORAL AND UMBILICAL HERNIA PROCEDURES",2284,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12259.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12259.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12259.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12259.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12259.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12627.41,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12259.62,12627.41,
OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,2291,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4412.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4412.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4412.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4412.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4412.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4544.83,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4412.46,4544.83,
OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,2292,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6122.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6122.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6122.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6122.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6122.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6305.74,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6122.08,6305.74,
OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,2293,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9171.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9171.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9171.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9171.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9171.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9446.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9171.44,9446.58,
OTHER DIGESTIVE SYSTEM AND ABDOMINAL PROCEDURES,2294,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15966.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15966.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15966.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15966.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15966.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16445.81,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15966.81,16445.81,
MAJOR SMALL BOWEL PROCEDURES,2301,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4991.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4991.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4991.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4991.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4991.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5140.94,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4991.2,5140.94,
MAJOR SMALL BOWEL PROCEDURES,2302,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6940.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6940.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6940.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6940.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6940.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7149.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6940.95,7149.18,
MAJOR SMALL BOWEL PROCEDURES,2303,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10250.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10250.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10250.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10250.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10250.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10558.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10250.92,10558.45,
MAJOR SMALL BOWEL PROCEDURES,2304,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18883.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18883.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18883.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18883.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18883.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19450.4,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18883.88,19450.4,
MAJOR LARGE BOWEL PROCEDURES,2311,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5403.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5403.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5403.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5403.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5403.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5565.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5403.51,5565.61,
MAJOR LARGE BOWEL PROCEDURES,2312,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6838.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6838.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6838.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6838.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6838.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7044.03,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6838.86,7044.03,
MAJOR LARGE BOWEL PROCEDURES,2313,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9936.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9936.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9936.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9936.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9936.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10234.48,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9936.39,10234.48,
MAJOR LARGE BOWEL PROCEDURES,2314,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16287.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16287.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16287.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16287.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16287.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16775.7,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16287.09,16775.7,
GASTRIC FUNDOPLICATION,2321,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4212.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4212.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4212.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4212.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4212.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4339.34,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4212.95,4339.34,
GASTRIC FUNDOPLICATION,2322,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5177.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5177.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5177.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5177.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5177.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5332.73,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5177.4,5332.73,
GASTRIC FUNDOPLICATION,2323,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7792.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7792.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7792.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7792.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7792.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8025.93,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7792.17,8025.93,
GASTRIC FUNDOPLICATION,2324,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23163.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23163.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23163.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,23163.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23163.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23858.6,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,23163.69,23858.6,
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,2331,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3909.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3909.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3909.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3909.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3909.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4026.48,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3909.2,4026.48,
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,2332,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4982.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4982.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4982.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4982.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4982.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5131.68,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4982.21,5131.68,
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,2333,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6977.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6977.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6977.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6977.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6977.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7186.57,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6977.25,7186.57,
APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,2334,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10939.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10939.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10939.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10939.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10939.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11267.85,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10939.66,11267.85,
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,2341,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3584.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3584.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3584.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3584.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3584.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3691.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3584.25,3691.77,
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,2342,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4340.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4340.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4340.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4340.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4340.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4471.15,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4340.92,4471.15,
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,2343,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6529.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6529.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6529.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6529.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6529.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6725.24,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6529.36,6725.24,
APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,2344,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11546.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11546.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11546.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11546.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11546.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11892.83,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11546.44,11892.83,
DIGESTIVE MALIGNANCY,2401,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3119.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3119.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3119.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3119.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3119.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3213.04,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3119.45,3213.04,
DIGESTIVE MALIGNANCY,2402,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3560.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3560.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3560.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3560.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3560.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3667.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3560.88,3667.71,
DIGESTIVE MALIGNANCY,2403,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5045.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5045.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5045.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5045.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5045.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5196.84,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5045.48,5196.84,
DIGESTIVE MALIGNANCY,2404,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8648.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8648.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8648.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8648.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8648.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8907.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8648.42,8907.87,
PEPTIC ULCER AND GASTRITIS,2411,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2423.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2423.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2423.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2423.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2423.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2496.6,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2423.89,2496.6,
PEPTIC ULCER AND GASTRITIS,2412,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2885.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2885.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2885.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2885.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2885.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2972,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2885.44,2972,
PEPTIC ULCER AND GASTRITIS,2413,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4363.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4363.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4363.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4363.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4363.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4494.85,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4363.93,4494.85,
PEPTIC ULCER AND GASTRITIS,2414,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8893.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8893.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8893.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8893.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8893.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9160.38,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8893.57,9160.38,
MAJOR ESOPHAGEAL DISORDERS,2421,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2177.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2177.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2177.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2177.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2177.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2242.98,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2177.65,2242.98,
MAJOR ESOPHAGEAL DISORDERS,2422,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2803.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2803.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2803.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2803.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2803.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2887.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2803.12,2887.22,
MAJOR ESOPHAGEAL DISORDERS,2423,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4091.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4091.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4091.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4091.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4091.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4214.2,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4091.45,4214.2,
MAJOR ESOPHAGEAL DISORDERS,2424,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8882.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8882.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8882.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8882.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8882.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9148.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8882.07,9148.53,
OTHER ESOPHAGEAL DISORDERS,2431,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2367.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2367.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2367.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2367.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2367.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2438.47,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2367.45,2438.47,
OTHER ESOPHAGEAL DISORDERS,2432,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2817.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2817.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2817.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2817.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2817.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2902.4,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2817.86,2902.4,
OTHER ESOPHAGEAL DISORDERS,2433,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4114.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4114.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4114.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4114.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4114.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4237.52,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4114.1,4237.52,
OTHER ESOPHAGEAL DISORDERS,2434,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7763.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7763.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7763.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7763.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7763.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7996.31,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7763.41,7996.31,
DIVERTICULITIS AND DIVERTICULOSIS,2441,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1939.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1939.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1939.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1939.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1939.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1997.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1939.68,1997.87,
DIVERTICULITIS AND DIVERTICULOSIS,2442,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2615.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2615.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2615.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2615.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2615.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2694.32,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2615.84,2694.32,
DIVERTICULITIS AND DIVERTICULOSIS,2443,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4119.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4119.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4119.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4119.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4119.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4242.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4119.13,4242.71,
DIVERTICULITIS AND DIVERTICULOSIS,2444,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7714.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7714.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7714.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7714.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7714.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7945.59,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7714.16,7945.59,
INFLAMMATORY BOWEL DISEASE,2451,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2175.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2175.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2175.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2175.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2175.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2241.13,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2175.85,2241.13,
INFLAMMATORY BOWEL DISEASE,2452,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2877.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2877.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2877.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2877.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2877.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2963.49,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2877.17,2963.49,
INFLAMMATORY BOWEL DISEASE,2453,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4425.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4425.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4425.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4425.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4425.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4557.79,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4425.04,4557.79,
INFLAMMATORY BOWEL DISEASE,2454,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7752.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7752.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7752.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7752.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7752.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7985.57,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7752.98,7985.57,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,2461,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2244.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2244.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2244.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2244.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2244.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2312.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2244.87,2312.22,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,2462,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2835.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2835.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2835.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2835.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2835.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2920.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2835.48,2920.54,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,2463,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4210.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4210.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4210.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4210.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4210.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4336.75,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4210.44,4336.75,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,2464,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6949.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6949.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6949.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6949.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6949.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7158.06,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6949.58,7158.06,
INTESTINAL OBSTRUCTION,2471,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1773.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1773.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1773.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1773.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1773.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1826.82,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1773.61,1826.82,
INTESTINAL OBSTRUCTION,2472,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2331.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2331.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2331.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2331.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2331.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2401.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2331.5,2401.45,
INTESTINAL OBSTRUCTION,2473,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3735.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3735.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3735.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3735.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3735.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3847.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3735.58,3847.65,
INTESTINAL OBSTRUCTION,2474,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7379.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7379.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7379.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7379.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7379.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7600.88,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7379.5,7600.88,
MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,2481,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2000.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2000.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2000.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2000.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2000.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2060.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2000.43,2060.45,
MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,2482,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2692.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2692.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2692.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2692.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2692.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2773.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2692.41,2773.18,
MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,2483,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4134.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4134.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4134.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4134.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4134.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4258.26,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4134.23,4258.26,
MAJOR GASTROINTESTINAL AND PERITONEAL INFECTIONS,2484,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7991.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7991.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7991.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7991.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7991.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8231.05,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7991.31,8231.05,
"OTHER GASTROENTERITIS, NAUSEA AND VOMITING",2491,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1880.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1880.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1880.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1880.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1880.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1937.15,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1880.73,1937.15,
"OTHER GASTROENTERITIS, NAUSEA AND VOMITING",2492,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2274.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2274.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2274.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2274.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2274.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2342.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2274.35,2342.58,
"OTHER GASTROENTERITIS, NAUSEA AND VOMITING",2493,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3394.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3394.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3394.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3394.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3394.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3496.28,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3394.45,3496.28,
"OTHER GASTROENTERITIS, NAUSEA AND VOMITING",2494,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6981.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6981.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6981.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6981.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6981.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7191.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6981.57,7191.02,
ABDOMINAL PAIN,2511,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2094.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2094.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2094.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2094.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2094.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2157.08,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2094.25,2157.08,
ABDOMINAL PAIN,2512,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2550.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2550.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2550.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2550.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2550.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2626.93,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2550.42,2626.93,
ABDOMINAL PAIN,2513,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3440.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3440.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3440.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3440.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3440.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3544.04,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3440.82,3544.04,
ABDOMINAL PAIN,2514,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5880.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5880.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5880.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5880.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5880.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6057.31,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5880.88,6057.31,
"MALFUNCTION, REACTION AND COMPLICATION OF GASTROINTESTINAL DEVICE OR PROCEDURE",2521,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2378.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2378.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2378.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2378.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2378.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2449.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2378.23,2449.58,
"MALFUNCTION, REACTION AND COMPLICATION OF GASTROINTESTINAL DEVICE OR PROCEDURE",2522,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2959.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2959.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2959.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2959.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2959.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3047.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2959.13,3047.91,
"MALFUNCTION, REACTION AND COMPLICATION OF GASTROINTESTINAL DEVICE OR PROCEDURE",2523,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4496.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4496.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4496.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4496.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4496.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4631.84,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4496.93,4631.84,
"MALFUNCTION, REACTION AND COMPLICATION OF GASTROINTESTINAL DEVICE OR PROCEDURE",2524,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9037.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9037.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9037.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9037.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9037.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9308.48,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9037.36,9308.48,
OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,2531,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2204.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2204.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2204.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2204.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2204.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2270.75,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2204.61,2270.75,
OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,2532,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2800.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2800.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2800.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2800.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2800.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2884.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2800.61,2884.63,
OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,2533,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4193.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4193.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4193.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4193.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4193.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4319.35,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4193.54,4319.35,
OTHER AND UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,2534,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7676.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7676.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7676.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7676.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7676.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7906.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7676.42,7906.71,
OTHER DIGESTIVE SYSTEM DIAGNOSES,2541,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2151.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2151.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2151.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2151.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2151.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2215.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2151.05,2215.58,
OTHER DIGESTIVE SYSTEM DIAGNOSES,2542,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2749.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2749.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2749.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2749.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2749.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2831.68,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2749.2,2831.68,
OTHER DIGESTIVE SYSTEM DIAGNOSES,2543,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4121.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4121.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4121.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4121.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4121.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4244.93,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4121.29,4244.93,
OTHER DIGESTIVE SYSTEM DIAGNOSES,2544,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7506.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7506.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7506.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7506.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7506.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7731.21,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7506.03,7731.21,
"MAJOR PANCREAS, LIVER AND SHUNT PROCEDURES",2601,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7190.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7190.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7190.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7190.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7190.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7406.5,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7190.78,7406.5,
"MAJOR PANCREAS, LIVER AND SHUNT PROCEDURES",2602,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8818.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8818.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8818.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8818.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8818.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9082.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8818.08,9082.63,
"MAJOR PANCREAS, LIVER AND SHUNT PROCEDURES",2603,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12203.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12203.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12203.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12203.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12203.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12569.28,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12203.19,12569.28,
"MAJOR PANCREAS, LIVER AND SHUNT PROCEDURES",2604,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23677.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23677.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23677.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,23677.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23677.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24387.32,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,23677.01,24387.32,
MAJOR BILIARY TRACT PROCEDURES,2611,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5614.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5614.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5614.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5614.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5614.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5782.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5614.52,5782.95,
MAJOR BILIARY TRACT PROCEDURES,2612,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7646.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7646.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7646.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7646.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7646.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7875.98,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7646.58,7875.98,
MAJOR BILIARY TRACT PROCEDURES,2613,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10617.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10617.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10617.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10617.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10617.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10935.73,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10617.22,10935.73,
MAJOR BILIARY TRACT PROCEDURES,2614,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20523.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20523.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20523.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,20523.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20523.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21139.11,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,20523.41,21139.11,
CHOLECYSTECTOMY,2631,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4307.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4307.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4307.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4307.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4307.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4437.09,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4307.85,4437.09,
CHOLECYSTECTOMY,2632,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5237.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5237.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5237.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5237.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5237.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5394.93,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5237.79,5394.93,
CHOLECYSTECTOMY,2633,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6625.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6625.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6625.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6625.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6625.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6824.1,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6625.34,6824.1,
CHOLECYSTECTOMY,2634,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13559.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13559.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13559.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13559.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13559.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13965.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13559.1,13965.87,
"OTHER HEPATOBILIARY, PANCREAS AND ABDOMINAL PROCEDURES",2641,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5271.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5271.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5271.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5271.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5271.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5429.73,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5271.58,5429.73,
"OTHER HEPATOBILIARY, PANCREAS AND ABDOMINAL PROCEDURES",2642,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5824.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5824.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5824.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5824.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5824.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5998.81,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5824.08,5998.81,
"OTHER HEPATOBILIARY, PANCREAS AND ABDOMINAL PROCEDURES",2643,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8953.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8953.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8953.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8953.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8953.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9221.84,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8953.24,9221.84,
"OTHER HEPATOBILIARY, PANCREAS AND ABDOMINAL PROCEDURES",2644,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19049.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19049.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19049.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,19049.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19049.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19621.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,19049.95,19621.45,
HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,2791,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1956.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1956.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1956.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1956.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1956.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2015.28,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1956.58,2015.28,
HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,2792,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2533.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2533.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2533.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2533.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2533.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2609.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2533.52,2609.53,
HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,2793,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4073.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4073.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4073.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4073.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4073.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4196.05,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4073.84,4196.05,
HEPATIC COMA AND OTHER MAJOR ACUTE LIVER DISORDERS,2794,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9054.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9054.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9054.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9054.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9054.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9326.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9054.97,9326.62,
ALCOHOLIC LIVER DISEASE,2801,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2036.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2036.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2036.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2036.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2036.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2097.84,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2036.74,2097.84,
ALCOHOLIC LIVER DISEASE,2802,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2668.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2668.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2668.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2668.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2668.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2748.37,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2668.32,2748.37,
ALCOHOLIC LIVER DISEASE,2803,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4235.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4235.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4235.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4235.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4235.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4362.3,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4235.24,4362.3,
ALCOHOLIC LIVER DISEASE,2804,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9330.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9330.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9330.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9330.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9330.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9610.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9330.68,9610.61,
MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,2811,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2850.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2850.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2850.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2850.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2850.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2935.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2850.21,2935.72,
MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,2812,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3591.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3591.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3591.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3591.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3591.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3699.55,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3591.79,3699.55,
MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,2813,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4771.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4771.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4771.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4771.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4771.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4914.34,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4771.21,4914.34,
MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,2814,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7367.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7367.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7367.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7367.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7367.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7588.29,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7367.28,7588.29,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,2821,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1990.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1990.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1990.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1990.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1990.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2050.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1990.73,2050.45,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,2822,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2630.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2630.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2630.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2630.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2630.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2709.5,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2630.58,2709.5,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,2823,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4319,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4319,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4319,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4319,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4319,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4448.57,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4319,4448.57,
DISORDERS OF PANCREAS EXCEPT MALIGNANCY,2824,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9918.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9918.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9918.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9918.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9918.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10215.97,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9918.41,10215.97,
OTHER DISORDERS OF THE LIVER,2831,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2055.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2055.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2055.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2055.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2055.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2117.47,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2055.79,2117.47,
OTHER DISORDERS OF THE LIVER,2832,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2609.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2609.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2609.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2609.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2609.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2688.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2609.73,2688.02,
OTHER DISORDERS OF THE LIVER,2833,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3972.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3972.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3972.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3972.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3972.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4091.27,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3972.11,4091.27,
OTHER DISORDERS OF THE LIVER,2834,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7974.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7974.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7974.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7974.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7974.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8213.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7974.42,8213.65,
DISORDERS OF GALLBLADDER AND BILIARY TRACT,2841,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2681.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2681.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2681.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2681.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2681.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2761.7,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2681.26,2761.7,
DISORDERS OF GALLBLADDER AND BILIARY TRACT,2842,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3399.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3399.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3399.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3399.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3399.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3501.83,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3399.84,3501.83,
DISORDERS OF GALLBLADDER AND BILIARY TRACT,2843,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4856.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4856.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4856.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4856.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4856.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5002.09,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4856.4,5002.09,
DISORDERS OF GALLBLADDER AND BILIARY TRACT,2844,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8672.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8672.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8672.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8672.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8672.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8933.05,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8672.86,8933.05,
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK,3031,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15181.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15181.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15181.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15181.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15181.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15637.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15181.73,15637.18,
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK,3032,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19069.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19069.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19069.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,19069.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19069.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19641.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,19069.36,19641.45,
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK,3033,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27175.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,27175.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,27175.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,27175.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,27175.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,27990.98,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,27175.71,27990.98,
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK,3034,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,39878.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,39878.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,39878.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,39878.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,39878.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,41074.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,39878.55,41074.91,
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,3041,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9963.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9963.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9963.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9963.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9963.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10262.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9963.71,10262.62,
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,3042,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12286.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12286.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12286.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12286.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12286.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12655.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12286.58,12655.18,
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,3043,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17983.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17983.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17983.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,17983.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17983.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18523.29,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,17983.77,18523.29,
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK,3044,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27960.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,27960.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,27960.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,27960.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,27960.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28798.86,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,27960.06,28798.86,
AMPUTATION OF LOWER LIMB EXCEPT TOES,3051,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3762.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3762.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3762.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3762.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3762.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3875.79,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3762.9,3875.79,
AMPUTATION OF LOWER LIMB EXCEPT TOES,3052,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5160.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5160.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5160.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5160.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5160.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5315.69,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5160.87,5315.69,
AMPUTATION OF LOWER LIMB EXCEPT TOES,3053,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8156.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8156.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8156.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8156.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8156.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8401,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8156.31,8401,
AMPUTATION OF LOWER LIMB EXCEPT TOES,3054,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15324.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15324.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15324.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15324.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15324.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15784.17,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15324.44,15784.17,
HIP AND FEMUR FRACTURE REPAIR,3081,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5014.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5014.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5014.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5014.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5014.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5164.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5014.21,5164.63,
HIP AND FEMUR FRACTURE REPAIR,3082,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5900.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5900.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5900.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5900.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5900.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6077.67,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5900.65,6077.67,
HIP AND FEMUR FRACTURE REPAIR,3083,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7834.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7834.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7834.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7834.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7834.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8069.99,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7834.94,8069.99,
HIP AND FEMUR FRACTURE REPAIR,3084,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12041.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12041.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12041.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12041.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12041.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12402.67,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12041.43,12402.67,
OTHER SIGNIFICANT HIP AND FEMUR SURGERY,3091,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5547.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5547.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5547.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5547.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5547.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5713.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5547.29,5713.71,
OTHER SIGNIFICANT HIP AND FEMUR SURGERY,3092,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7177.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7177.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7177.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7177.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7177.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7392.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7177.48,7392.8,
OTHER SIGNIFICANT HIP AND FEMUR SURGERY,3093,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10424.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10424.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10424.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10424.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10424.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10737.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10424.9,10737.65,
OTHER SIGNIFICANT HIP AND FEMUR SURGERY,3094,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15861.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15861.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15861.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15861.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15861.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16336.96,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15861.12,16336.96,
VERTEBRAL AND INTERVERTEBRAL SPINAL PROCEDURES INCLUDING DISC PROCEDURES,3101,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4572.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4572.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4572.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4572.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4572.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4709.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4572.06,4709.22,
VERTEBRAL AND INTERVERTEBRAL SPINAL PROCEDURES INCLUDING DISC PROCEDURES,3102,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6136.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6136.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6136.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6136.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6136.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6320.55,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6136.46,6320.55,
VERTEBRAL AND INTERVERTEBRAL SPINAL PROCEDURES INCLUDING DISC PROCEDURES,3103,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8464.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8464.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8464.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8464.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8464.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8717.93,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8464.01,8717.93,
VERTEBRAL AND INTERVERTEBRAL SPINAL PROCEDURES INCLUDING DISC PROCEDURES,3104,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16193.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16193.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16193.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16193.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16193.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16679.81,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16193.99,16679.81,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES",3121,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5473.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5473.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5473.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5473.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5473.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5637.81,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5473.6,5637.81,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES",3122,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8421.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8421.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8421.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8421.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8421.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8674.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8421.95,8674.61,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES",3123,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13864.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13864.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13864.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13864.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13864.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14280.21,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13864.28,14280.21,
"SKIN GRAFT, EXCEPT HAND, FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DIAGNOSES",3124,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26183.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26183.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26183.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,26183.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26183.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26969.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,26183.94,26969.45,
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,3131,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5189.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5189.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5189.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5189.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5189.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5344.94,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5189.27,5344.94,
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,3132,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6659.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6659.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6659.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6659.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6659.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6858.9,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6659.13,6858.9,
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,3133,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9892.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9892.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9892.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9892.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9892.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10189.31,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9892.53,10189.31,
KNEE AND LOWER LEG PROCEDURES EXCEPT FOOT,3134,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15896.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15896.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15896.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15896.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15896.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16373.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15896.71,16373.61,
FOOT AND TOE PROCEDURES,3141,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4453.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4453.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4453.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4453.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4453.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4586.67,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4453.08,4586.67,
FOOT AND TOE PROCEDURES,3142,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4496.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4496.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4496.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4496.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4496.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4631.84,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4496.93,4631.84,
FOOT AND TOE PROCEDURES,3143,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6107.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6107.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6107.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6107.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6107.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6290.93,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6107.7,6290.93,
FOOT AND TOE PROCEDURES,3144,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11079.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11079.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11079.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11079.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11079.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11411.88,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11079.49,11411.88,
"SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT",3151,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4295.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4295.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4295.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4295.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4295.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4424.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4295.99,4424.87,
"SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT",3152,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6276.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6276.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6276.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6276.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6276.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6464.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6276.65,6464.95,
"SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT",3153,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9333.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9333.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9333.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9333.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9333.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9613.94,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9333.92,9613.94,
"SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT",3154,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16378.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16378.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16378.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16378.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16378.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16869.38,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16378.04,16869.38,
HAND AND WRIST PROCEDURES,3161,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3607.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3607.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3607.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3607.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3607.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3715.84,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3607.61,3715.84,
HAND AND WRIST PROCEDURES,3162,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4674.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4674.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4674.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4674.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4674.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4815.11,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4674.87,4815.11,
HAND AND WRIST PROCEDURES,3163,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7139.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7139.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7139.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7139.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7139.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7353.93,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7139.73,7353.93,
HAND AND WRIST PROCEDURES,3164,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13590.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13590.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13590.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13590.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13590.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13997.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13590.01,13997.71,
"TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES",3171,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3884.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3884.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3884.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3884.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3884.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4000.56,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3884.04,4000.56,
"TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES",3172,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5064.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5064.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5064.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5064.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5064.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5216.84,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5064.89,5216.84,
"TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES",3173,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7843.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7843.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7843.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7843.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7843.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8078.88,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7843.57,8078.88,
"TENDON, MUSCLE AND OTHER SOFT TISSUE PROCEDURES",3174,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14570.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14570.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14570.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,14570.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14570.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15007.75,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,14570.64,15007.75,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE PROCEDURES,3201,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4253.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4253.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4253.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4253.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4253.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4381.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4253.57,4381.18,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE PROCEDURES,3202,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5981.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5981.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5981.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5981.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5981.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6161.35,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5981.89,6161.35,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE PROCEDURES,3203,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8736.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8736.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8736.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8736.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8736.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8998.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8736.49,8998.58,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE PROCEDURES,3204,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15984.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15984.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15984.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15984.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15984.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16463.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15984.06,16463.58,
SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,3211,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6744.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6744.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6744.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6744.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6744.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6946.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6744.32,6946.65,
SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,3212,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8307.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8307.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8307.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8307.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8307.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8556.5,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8307.28,8556.5,
SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,3213,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11710.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11710.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11710.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11710.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11710.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12061.67,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11710.36,12061.67,
SPINAL FUSION AND OTHER BACK AND NECK PROCEDURES EXCEPT FOR DISC PROCEDURES,3214,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18887.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18887.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18887.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18887.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18887.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19454.47,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18887.83,19454.47,
SHOULDER AND ELBOW JOINT REPLACEMENT,3221,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5814.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5814.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5814.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5814.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5814.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5988.81,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5814.38,5988.81,
SHOULDER AND ELBOW JOINT REPLACEMENT,3222,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6487.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6487.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6487.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6487.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6487.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6682.29,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6487.66,6682.29,
SHOULDER AND ELBOW JOINT REPLACEMENT,3223,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9363.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9363.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9363.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9363.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9363.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9644.3,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9363.4,9644.3,
SHOULDER AND ELBOW JOINT REPLACEMENT,3224,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13162.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13162.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13162.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13162.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13162.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13557.85,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13162.96,13557.85,
NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT,3231,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5740.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5740.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5740.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5740.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5740.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5912.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5740.69,5912.91,
NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT,3232,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6583.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6583.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6583.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6583.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6583.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6780.78,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6583.28,6780.78,
NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT,3233,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9107.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9107.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9107.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9107.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9107.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9380.31,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9107.1,9380.31,
NON-ELECTIVE OR COMPLEX HIP JOINT REPLACEMENT,3234,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13161.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13161.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13161.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13161.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13161.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13556,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13161.17,13556,
ELECTIVE HIP JOINT REPLACEMENT,3241,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4818.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4818.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4818.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4818.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4818.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4962.84,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4818.3,4962.84,
ELECTIVE HIP JOINT REPLACEMENT,3242,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5503.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5503.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5503.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5503.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5503.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5668.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5503.44,5668.54,
ELECTIVE HIP JOINT REPLACEMENT,3243,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8216.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8216.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8216.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8216.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8216.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8462.83,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8216.34,8462.83,
ELECTIVE HIP JOINT REPLACEMENT,3244,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13850.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13850.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13850.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13850.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13850.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14265.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13850.26,14265.77,
NON-ELECTIVE OR COMPLEX KNEE JOINT REPLACEMENT,3251,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7545.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7545.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7545.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7545.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7545.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7772.31,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7545.93,7772.31,
NON-ELECTIVE OR COMPLEX KNEE JOINT REPLACEMENT,3252,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8787.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8787.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8787.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8787.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8787.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9050.79,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8787.17,9050.79,
NON-ELECTIVE OR COMPLEX KNEE JOINT REPLACEMENT,3253,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11673.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11673.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11673.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11673.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11673.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12023.9,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11673.69,12023.9,
NON-ELECTIVE OR COMPLEX KNEE JOINT REPLACEMENT,3254,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17087.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17087.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17087.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,17087.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17087.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17599.88,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,17087.26,17599.88,
ELECTIVE KNEE JOINT REPLACEMENT,3261,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4746.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4746.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4746.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4746.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4746.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4889.16,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4746.76,4889.16,
ELECTIVE KNEE JOINT REPLACEMENT,3262,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5289.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5289.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5289.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5289.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5289.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5447.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5289.2,5447.87,
ELECTIVE KNEE JOINT REPLACEMENT,3263,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7556,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7556,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7556,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7556,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7556,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7782.68,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7556,7782.68,
ELECTIVE KNEE JOINT REPLACEMENT,3264,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11530.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11530.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11530.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11530.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11530.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11876.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11530.62,11876.54,
FRACTURE OF FEMUR,3401,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1825.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1825.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1825.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1825.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1825.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1880.5,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1825.73,1880.5,
FRACTURE OF FEMUR,3402,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2315.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2315.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2315.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2315.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2315.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2384.79,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2315.33,2384.79,
FRACTURE OF FEMUR,3403,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3428.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3428.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3428.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3428.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3428.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3531.08,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3428.24,3531.08,
FRACTURE OF FEMUR,3404,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5718.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5718.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5718.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5718.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5718.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5889.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5718.4,5889.95,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,3411,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2010.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2010.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2010.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2010.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2010.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2070.81,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2010.5,2070.81,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,3412,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2410.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2410.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2410.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2410.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2410.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2483.27,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2410.95,2483.27,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,3413,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3268.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3268.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3268.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3268.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3268.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3367.06,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3268.99,3367.06,
FRACTURE OF PELVIS OR DISLOCATION OF HIP,3414,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5976.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5976.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5976.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5976.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5976.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6156.16,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5976.86,6156.16,
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK",3421,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2262.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2262.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2262.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2262.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2262.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2330.73,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2262.84,2330.73,
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK",3422,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2777.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2777.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2777.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2777.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2777.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2860.56,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2777.24,2860.56,
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK",3423,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3983.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3983.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3983.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3983.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3983.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4103.49,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3983.97,4103.49,
"FRACTURES AND DISLOCATIONS EXCEPT FEMUR, PELVIS AND BACK",3424,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7145.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7145.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7145.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7145.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7145.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7360.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7145.84,7360.22,
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY,3431,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3278.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3278.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3278.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3278.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3278.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3377.06,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3278.7,3377.06,
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY,3432,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3824.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3824.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3824.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3824.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3824.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3939.1,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3824.37,3939.1,
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY,3433,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5875.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5875.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5875.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5875.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5875.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6051.75,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5875.49,6051.75,
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FRACTURE DUE TO MUSCULOSKELETAL MALIGNANCY,3434,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9923.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9923.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9923.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9923.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9923.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10221.52,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9923.81,10221.52,
"OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS",3441,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2763.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2763.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2763.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2763.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2763.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2846.12,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2763.22,2846.12,
"OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS",3442,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3462.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3462.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3462.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3462.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3462.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3566.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3462.75,3566.63,
"OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS",3443,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5084.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5084.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5084.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5084.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5084.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5236.83,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5084.3,5236.83,
"OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS",3444,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8290.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8290.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8290.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8290.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8290.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8539.1,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8290.39,8539.1,
CONNECTIVE TISSUE DISORDERS,3461,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2764.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2764.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2764.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2764.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2764.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2847.6,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2764.66,2847.6,
CONNECTIVE TISSUE DISORDERS,3462,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3680.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3680.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3680.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3680.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3680.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3790.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3680.22,3790.63,
CONNECTIVE TISSUE DISORDERS,3463,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5719.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5719.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5719.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5719.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5719.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5891.43,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5719.84,5891.43,
CONNECTIVE TISSUE DISORDERS,3464,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12101.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12101.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12101.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12101.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12101.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12464.13,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12101.1,12464.13,
"OTHER BACK AND NECK DISORDERS, FRACTURES AND INJURIES",3471,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2645.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2645.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2645.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2645.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2645.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2725.05,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2645.68,2725.05,
"OTHER BACK AND NECK DISORDERS, FRACTURES AND INJURIES",3472,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3197.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3197.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3197.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3197.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3197.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3293.38,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3197.46,3293.38,
"OTHER BACK AND NECK DISORDERS, FRACTURES AND INJURIES",3473,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4410.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4410.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4410.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4410.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4410.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4542.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4410.3,4542.61,
"OTHER BACK AND NECK DISORDERS, FRACTURES AND INJURIES",3474,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8107.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8107.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8107.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8107.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8107.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8350.27,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8107.06,8350.27,
"MALFUNCTION, REACTION, COMPLICATION OF ORTHOPEDIC DEVICE OR PROCEDURE",3491,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2344.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2344.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2344.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2344.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2344.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2415.15,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2344.8,2415.15,
"MALFUNCTION, REACTION, COMPLICATION OF ORTHOPEDIC DEVICE OR PROCEDURE",3492,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3180.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3180.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3180.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3180.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3180.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3276.35,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3180.92,3276.35,
"MALFUNCTION, REACTION, COMPLICATION OF ORTHOPEDIC DEVICE OR PROCEDURE",3493,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4578.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4578.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4578.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4578.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4578.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4716.26,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4578.89,4716.26,
"MALFUNCTION, REACTION, COMPLICATION OF ORTHOPEDIC DEVICE OR PROCEDURE",3494,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7958.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7958.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7958.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7958.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7958.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8196.99,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7958.24,8196.99,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,3511,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2272.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2272.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2272.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2272.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2272.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2341.1,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2272.91,2341.1,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,3512,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2493.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2493.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2493.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2493.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2493.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2568.06,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2493.26,2568.06,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,3513,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3894.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3894.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3894.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3894.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3894.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4010.93,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3894.11,4010.93,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,3514,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7387.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7387.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7387.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7387.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7387.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7609.4,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7387.77,7609.4,
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES,3611,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6099.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6099.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6099.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6099.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6099.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6282.79,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6099.8,6282.79,
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES,3612,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7558.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7558.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7558.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7558.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7558.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7785.64,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7558.87,7785.64,
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES,3613,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11790.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11790.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11790.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11790.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11790.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12144.23,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11790.52,12144.23,
SKIN GRAFT FOR SKIN AND SUBCUTANEOUS TISSUE DIAGNOSES,3614,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25369.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25369.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25369.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,25369.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25369.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26130.84,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,25369.74,26130.84,
MASTECTOMY PROCEDURES,3621,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5532.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5532.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5532.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5532.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5532.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5698.9,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5532.92,5698.9,
MASTECTOMY PROCEDURES,3622,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8350.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8350.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8350.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8350.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8350.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8600.93,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8350.42,8600.93,
MASTECTOMY PROCEDURES,3623,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9085.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9085.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9085.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9085.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9085.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9357.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9085.17,9357.72,
MASTECTOMY PROCEDURES,3624,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12350.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12350.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12350.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12350.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12350.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12720.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12350.21,12720.71,
BREAST PROCEDURES EXCEPT MASTECTOMY,3631,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4821.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4821.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4821.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4821.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4821.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4965.81,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4821.17,4965.81,
BREAST PROCEDURES EXCEPT MASTECTOMY,3632,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8020.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8020.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8020.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8020.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8020.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8260.67,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8020.07,8260.67,
BREAST PROCEDURES EXCEPT MASTECTOMY,3633,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9972.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9972.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9972.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9972.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9972.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10271.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9972.69,10271.87,
BREAST PROCEDURES EXCEPT MASTECTOMY,3634,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18978.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18978.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18978.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18978.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18978.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19547.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18978.42,19547.77,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES",3641,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3107.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3107.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3107.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3107.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3107.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3201.19,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3107.95,3201.19,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES",3642,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4176.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4176.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4176.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4176.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4176.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4301.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4176.29,4301.58,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES",3643,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6827.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6827.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6827.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6827.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6827.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7032.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6827.36,7032.18,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND RELATED PROCEDURES",3644,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12852.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12852.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12852.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12852.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12852.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13237.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12852.02,13237.58,
SKIN ULCERS,3801,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2113.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2113.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2113.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2113.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2113.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2176.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2113.31,2176.71,
SKIN ULCERS,3802,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2689.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2689.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2689.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2689.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2689.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2769.85,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2689.17,2769.85,
SKIN ULCERS,3803,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4199.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4199.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4199.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4199.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4199.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4325.64,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4199.65,4325.64,
SKIN ULCERS,3804,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7717.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7717.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7717.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7717.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7717.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7948.92,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7717.4,7948.92,
MAJOR SKIN DISORDERS,3811,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1645.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1645.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1645.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1645.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1645.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1695.01,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1645.64,1695.01,
MAJOR SKIN DISORDERS,3812,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2834.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2834.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2834.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2834.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2834.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2919.43,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2834.4,2919.43,
MAJOR SKIN DISORDERS,3813,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5643.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5643.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5643.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5643.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5643.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5813.31,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5643.99,5813.31,
MAJOR SKIN DISORDERS,3814,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11700.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11700.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11700.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11700.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11700.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12051.3,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11700.29,12051.3,
MALIGNANT BREAST DISORDERS,3821,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2775.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2775.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2775.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2775.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2775.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2858.34,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2775.09,2858.34,
MALIGNANT BREAST DISORDERS,3822,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3205.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3205.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3205.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3205.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3205.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3301.9,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3205.73,3301.9,
MALIGNANT BREAST DISORDERS,3823,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4593.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4593.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4593.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4593.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4593.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4731.81,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4593.99,4731.81,
MALIGNANT BREAST DISORDERS,3824,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6889.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6889.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6889.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6889.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6889.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7095.86,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6889.19,7095.86,
CELLULITIS AND OTHER SKIN INFECTIONS,3831,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1757.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1757.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1757.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1757.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1757.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1810.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1757.79,1810.53,
CELLULITIS AND OTHER SKIN INFECTIONS,3832,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2302.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2302.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2302.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2302.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2302.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2371.83,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2302.75,2371.83,
CELLULITIS AND OTHER SKIN INFECTIONS,3833,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3604.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3604.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3604.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3604.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3604.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3712.14,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3604.02,3712.14,
CELLULITIS AND OTHER SKIN INFECTIONS,3834,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7280.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7280.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7280.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7280.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7280.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7498.69,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7280.29,7498.69,
"CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE",3841,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2618.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2618.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2618.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2618.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2618.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2696.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2618.36,2696.91,
"CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE",3842,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3007.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3007.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3007.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3007.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3007.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3097.89,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3007.66,3097.89,
"CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE",3843,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4360.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4360.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4360.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4360.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4360.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4491.14,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4360.33,4491.14,
"CONTUSION, OPEN WOUND AND OTHER TRAUMA TO SKIN AND SUBCUTANEOUS TISSUE",3844,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7276.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7276.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7276.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7276.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7276.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7494.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7276.33,7494.62,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS",3851,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1958.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1958.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1958.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1958.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1958.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2017.13,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1958.38,2017.13,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS",3852,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2461.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2461.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2461.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2461.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2461.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2535.11,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2461.27,2535.11,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS",3853,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3946.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3946.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3946.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3946.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3946.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4065.36,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3946.95,4065.36,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DISORDERS",3854,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7691.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7691.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7691.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7691.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7691.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7922.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7691.87,7922.63,
ADRENAL PROCEDURES,4011,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5084.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5084.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5084.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5084.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5084.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5237.2,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5084.66,5237.2,
ADRENAL PROCEDURES,4012,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8943.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8943.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8943.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8943.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8943.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9211.47,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8943.18,9211.47,
ADRENAL PROCEDURES,4013,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12791.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12791.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12791.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12791.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12791.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13175.01,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12791.27,13175.01,
ADRENAL PROCEDURES,4014,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17921.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17921.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17921.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,17921.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17921.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18459.23,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,17921.59,18459.23,
PROCEDURES FOR OBESITY,4031,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4317.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4317.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4317.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4317.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4317.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4447.46,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4317.92,4447.46,
PROCEDURES FOR OBESITY,4032,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4930.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4930.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4930.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4930.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4930.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5078.36,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4930.45,5078.36,
PROCEDURES FOR OBESITY,4033,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8059.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8059.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8059.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8059.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8059.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8301.03,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8059.25,8301.03,
PROCEDURES FOR OBESITY,4034,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17881.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17881.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17881.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,17881.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17881.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18418.14,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,17881.69,18418.14,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES",4041,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4049.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4049.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4049.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4049.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4049.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4171.25,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4049.76,4171.25,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES",4042,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5668.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5668.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5668.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5668.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5668.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5838.12,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5668.08,5838.12,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES",4043,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9597.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9597.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9597.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9597.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9597.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9885.33,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9597.41,9885.33,
"THYROID, PARATHYROID AND THYROGLOSSAL PROCEDURES",4044,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18902.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18902.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18902.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18902.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18902.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19470.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18902.93,19470.02,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS",4051,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5474.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5474.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5474.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5474.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5474.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5638.55,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5474.32,5638.55,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS",4052,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5887.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5887.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5887.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5887.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5887.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6063.97,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5887.35,6063.97,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS",4053,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9015.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9015.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9015.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9015.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9015.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9286.27,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9015.79,9286.27,
"OTHER PROCEDURES FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS",4054,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18177.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18177.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18177.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18177.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18177.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18723.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18177.89,18723.22,
DIABETES,4201,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1848.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1848.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1848.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1848.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1848.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1904.2,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1848.74,1904.2,
DIABETES,4202,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2148.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2148.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2148.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2148.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2148.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2212.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2148.17,2212.62,
DIABETES,4203,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3350.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3350.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3350.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3350.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3350.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3451.48,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3350.95,3451.48,
DIABETES,4204,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7281,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7281,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7281,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7281,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7281,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7499.43,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7281,7499.43,
"MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS",4211,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1966.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1966.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1966.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1966.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1966.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2025.64,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1966.64,2025.64,
"MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS",4212,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2659.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2659.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2659.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2659.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2659.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2739.12,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2659.34,2739.12,
"MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS",4213,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4203.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4203.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4203.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4203.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4203.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4330.09,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4203.97,4330.09,
"MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DISORDERS",4214,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8384.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8384.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8384.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8384.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8384.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8635.73,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8384.21,8635.73,
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,4221,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1524.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1524.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1524.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1524.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1524.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1569.86,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1524.14,1569.86,
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,4222,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2034.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2034.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2034.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2034.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2034.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2095.25,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2034.22,2095.25,
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,4223,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3009.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3009.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3009.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3009.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3009.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3099.37,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3009.1,3099.37,
HYPOVOLEMIA AND RELATED ELECTROLYTE DISORDERS,4224,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5362.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5362.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5362.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5362.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5362.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5523.03,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5362.17,5523.03,
INBORN ERRORS OF METABOLISM,4231,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2786.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2786.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2786.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2786.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2786.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2870.19,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2786.59,2870.19,
INBORN ERRORS OF METABOLISM,4232,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3079.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3079.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3079.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3079.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3079.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3172.31,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3079.91,3172.31,
INBORN ERRORS OF METABOLISM,4233,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5303.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5303.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5303.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5303.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5303.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5462.31,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5303.22,5462.31,
INBORN ERRORS OF METABOLISM,4234,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15310.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15310.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15310.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15310.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15310.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15770.1,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15310.78,15770.1,
OTHER ENDOCRINE DISORDERS,4241,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2173.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2173.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2173.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2173.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2173.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2238.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2173.7,2238.91,
OTHER ENDOCRINE DISORDERS,4242,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3047.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3047.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3047.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3047.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3047.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3139.36,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3047.92,3139.36,
OTHER ENDOCRINE DISORDERS,4243,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4543.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4543.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4543.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4543.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4543.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4679.97,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4543.66,4679.97,
OTHER ENDOCRINE DISORDERS,4244,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8173.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8173.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8173.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8173.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8173.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8418.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8173.56,8418.77,
OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,4251,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1706.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1706.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1706.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1706.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1706.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1757.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1706.39,1757.58,
OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,4252,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2162.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2162.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2162.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2162.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2162.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2227.06,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2162.19,2227.06,
OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,4253,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3211.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3211.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3211.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3211.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3211.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3307.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3211.12,3307.45,
OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,4254,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7072.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7072.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7072.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7072.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7072.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7284.32,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7072.15,7284.32,
NON-HYPOVOLEMIC SODIUM DISORDERS,4261,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1802.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1802.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1802.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1802.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1802.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1856.07,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1802.01,1856.07,
NON-HYPOVOLEMIC SODIUM DISORDERS,4262,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2395.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2395.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2395.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2395.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2395.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2467.35,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2395.49,2467.35,
NON-HYPOVOLEMIC SODIUM DISORDERS,4263,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3715.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3715.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3715.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3715.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3715.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3826.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3715.09,3826.54,
NON-HYPOVOLEMIC SODIUM DISORDERS,4264,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6914.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6914.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6914.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6914.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6914.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7121.78,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6914.35,7121.78,
THYROID DISORDERS,4271,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2045.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2045.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2045.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2045.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2045.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2106.73,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2045.37,2106.73,
THYROID DISORDERS,4272,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2630.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2630.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2630.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2630.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2630.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2709.5,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2630.58,2709.5,
THYROID DISORDERS,4273,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4118.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4118.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4118.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4118.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4118.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4242.34,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4118.77,4242.34,
THYROID DISORDERS,4274,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8559.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8559.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8559.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8559.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8559.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8816.05,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8559.27,8816.05,
KIDNEY TRANSPLANT,4401,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17310.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17310.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17310.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,17310.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17310.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17829.44,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,17310.13,17829.44,
KIDNEY TRANSPLANT,4402,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18763.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18763.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18763.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18763.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18763.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19326.73,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18763.82,19326.73,
KIDNEY TRANSPLANT,4403,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21467.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21467.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21467.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,21467.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21467.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22111.39,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,21467.37,22111.39,
KIDNEY TRANSPLANT,4404,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35422.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,35422.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,35422.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,35422.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,35422.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,36485.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,35422.96,36485.65,
MAJOR BLADDER PROCEDURES,4411,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5196.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5196.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5196.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5196.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5196.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5352.35,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5196.45,5352.35,
MAJOR BLADDER PROCEDURES,4412,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8432.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8432.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8432.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8432.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8432.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8685.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8432.74,8685.72,
MAJOR BLADDER PROCEDURES,4413,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11293.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11293.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11293.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11293.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11293.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11632.55,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11293.73,11632.55,
MAJOR BLADDER PROCEDURES,4414,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20918.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20918.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20918.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,20918.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20918.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21546.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,20918.46,21546.02,
KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY,4421,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5172.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5172.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5172.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5172.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5172.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5327.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5172.37,5327.54,
KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY,4422,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6004.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6004.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6004.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6004.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6004.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6184.3,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6004.18,6184.3,
KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY,4423,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9163.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9163.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9163.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9163.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9163.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9438.07,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9163.17,9438.07,
KIDNEY AND URINARY TRACT PROCEDURES FOR MALIGNANCY,4424,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16744.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16744.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16744.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16744.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16744.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17246.66,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16744.33,17246.66,
KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,4431,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4719.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4719.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4719.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4719.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4719.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4861.03,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4719.44,4861.03,
KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,4432,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5471.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5471.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5471.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5471.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5471.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5635.59,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5471.45,5635.59,
KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,4433,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8048.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8048.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8048.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8048.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8048.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8290.29,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8048.83,8290.29,
KIDNEY AND URINARY TRACT PROCEDURES FOR NON-MALIGNANCY,4434,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14888.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14888.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14888.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,14888.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14888.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15335.43,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,14888.76,15335.43,
RENAL DIALYSIS ACCESS DEVICE PROCEDURES,4441,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3993.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3993.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3993.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3993.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3993.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4113.49,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3993.68,4113.49,
RENAL DIALYSIS ACCESS DEVICE PROCEDURES,4442,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5848.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5848.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5848.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5848.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5848.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6023.98,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5848.53,6023.98,
RENAL DIALYSIS ACCESS DEVICE PROCEDURES,4443,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8674.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8674.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8674.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8674.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8674.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8934.9,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8674.66,8934.9,
RENAL DIALYSIS ACCESS DEVICE PROCEDURES,4444,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15492.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15492.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15492.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15492.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15492.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15957.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15492.67,15957.45,
OTHER BLADDER PROCEDURES,4451,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3911.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3911.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3911.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3911.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3911.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4028.7,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3911.36,4028.7,
OTHER BLADDER PROCEDURES,4452,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4830.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4830.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4830.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4830.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4830.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4975.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4830.88,4975.8,
OTHER BLADDER PROCEDURES,4453,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7012.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7012.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7012.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7012.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7012.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7222.49,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7012.12,7222.49,
OTHER BLADDER PROCEDURES,4454,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13218.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13218.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13218.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13218.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13218.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13615.24,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13218.68,13615.24,
URETHRAL AND TRANSURETHRAL PROCEDURES,4461,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3381.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3381.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3381.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3381.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3381.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3483.32,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3381.87,3483.32,
URETHRAL AND TRANSURETHRAL PROCEDURES,4462,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4016.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4016.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4016.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4016.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4016.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4137.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4016.68,4137.18,
URETHRAL AND TRANSURETHRAL PROCEDURES,4463,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6507.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6507.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6507.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6507.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6507.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6702.28,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6507.07,6702.28,
URETHRAL AND TRANSURETHRAL PROCEDURES,4464,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11921,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11921,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11921,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11921,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11921,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12278.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11921,12278.63,
"OTHER KIDNEY, URINARY TRACT AND RELATED PROCEDURES",4471,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4927.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4927.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4927.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4927.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4927.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5075.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4927.93,5075.77,
"OTHER KIDNEY, URINARY TRACT AND RELATED PROCEDURES",4472,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5924.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5924.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5924.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5924.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5924.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6101.74,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5924.02,6101.74,
"OTHER KIDNEY, URINARY TRACT AND RELATED PROCEDURES",4473,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8569.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8569.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8569.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8569.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8569.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8826.78,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8569.69,8826.78,
"OTHER KIDNEY, URINARY TRACT AND RELATED PROCEDURES",4474,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16937.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16937.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16937.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16937.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16937.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17445.86,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16937.73,17445.86,
KIDNEY AND URINARY TRACT MALIGNANCY,4611,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2805.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2805.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2805.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2805.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2805.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2889.81,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2805.64,2889.81,
KIDNEY AND URINARY TRACT MALIGNANCY,4612,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3215.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3215.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3215.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3215.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3215.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3312.27,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3215.79,3312.27,
KIDNEY AND URINARY TRACT MALIGNANCY,4613,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4880.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4880.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4880.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4880.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4880.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5026.9,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4880.48,5026.9,
KIDNEY AND URINARY TRACT MALIGNANCY,4614,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7753.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7753.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7753.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7753.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7753.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7985.94,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7753.34,7985.94,
NEPHRITIS AND NEPHROSIS,4621,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2046.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2046.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2046.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2046.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2046.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2108.21,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2046.81,2108.21,
NEPHRITIS AND NEPHROSIS,4622,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2824.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2824.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2824.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2824.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2824.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2909.43,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2824.69,2909.43,
NEPHRITIS AND NEPHROSIS,4623,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5255.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5255.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5255.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5255.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5255.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5413.07,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5255.41,5413.07,
NEPHRITIS AND NEPHROSIS,4624,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9645.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9645.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9645.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9645.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9645.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9934.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9645.22,9934.58,
KIDNEY AND URINARY TRACT INFECTIONS,4631,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1935.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1935.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1935.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1935.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1935.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1993.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1935.73,1993.8,
KIDNEY AND URINARY TRACT INFECTIONS,4632,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2287.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2287.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2287.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2287.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2287.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2355.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2287.29,2355.91,
KIDNEY AND URINARY TRACT INFECTIONS,4633,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3177.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3177.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3177.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3177.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3177.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3273.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3177.69,3273.02,
KIDNEY AND URINARY TRACT INFECTIONS,4634,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5627.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5627.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5627.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5627.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5627.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5795.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5627.1,5795.91,
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION,4651,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2134.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2134.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2134.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2134.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2134.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2198.92,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2134.87,2198.92,
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION,4652,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2529.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2529.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2529.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2529.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2529.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2605.46,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2529.57,2605.46,
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION,4653,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4064.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4064.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4064.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4064.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4064.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4186.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4064.85,4186.8,
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION,4654,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7092.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7092.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7092.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7092.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7092.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7305.42,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7092.64,7305.42,
"MALFUNCTION, REACTION, COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE",4661,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1897.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1897.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1897.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1897.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1897.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1954.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1897.27,1954.18,
"MALFUNCTION, REACTION, COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE",4662,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2455.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2455.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2455.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2455.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2455.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2529.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2455.52,2529.18,
"MALFUNCTION, REACTION, COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE",4663,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3696.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3696.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3696.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3696.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3696.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3807.29,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3696.4,3807.29,
"MALFUNCTION, REACTION, COMPLICATION OF GENITOURINARY DEVICE OR PROCEDURE",4664,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6071.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6071.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6071.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6071.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6071.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6253.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6071.76,6253.91,
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS",4681,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2017.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2017.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2017.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2017.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2017.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2078.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2017.69,2078.22,
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS",4682,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2649.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2649.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2649.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2649.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2649.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2729.49,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2649.99,2729.49,
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS",4683,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3897.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3897.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3897.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3897.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3897.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4014.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3897.7,4014.63,
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS",4684,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7327.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7327.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7327.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7327.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7327.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7547.2,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7327.38,7547.2,
ACUTE KIDNEY INJURY,4691,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1765.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1765.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1765.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1765.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1765.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1818.67,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1765.7,1818.67,
ACUTE KIDNEY INJURY,4692,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2392.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2392.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2392.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2392.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2392.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2464.76,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2392.97,2464.76,
ACUTE KIDNEY INJURY,4693,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4018.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4018.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4018.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4018.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4018.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4138.67,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4018.12,4138.67,
ACUTE KIDNEY INJURY,4694,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8289.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8289.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8289.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8289.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8289.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8538.36,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8289.67,8538.36,
CHRONIC KIDNEY DISEASE,4701,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1794.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1794.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1794.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1794.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1794.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1848.29,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1794.46,1848.29,
CHRONIC KIDNEY DISEASE,4702,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2355.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2355.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2355.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2355.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2355.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2426.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2355.95,2426.63,
CHRONIC KIDNEY DISEASE,4703,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3838.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3838.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3838.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3838.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3838.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3953.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3838.75,3953.91,
CHRONIC KIDNEY DISEASE,4704,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7942.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7942.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7942.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7942.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7942.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8180.33,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7942.06,8180.33,
MAJOR MALE PELVIC PROCEDURES,4801,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4947.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4947.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4947.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4947.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4947.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5095.76,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4947.34,5095.76,
MAJOR MALE PELVIC PROCEDURES,4802,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5568.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5568.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5568.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5568.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5568.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5735.56,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5568.5,5735.56,
MAJOR MALE PELVIC PROCEDURES,4803,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9741.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9741.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9741.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9741.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9741.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10033.43,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9741.2,10033.43,
MAJOR MALE PELVIC PROCEDURES,4804,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16220.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16220.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16220.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16220.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16220.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16707.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16220.95,16707.58,
TRANSURETHRAL PROSTATECTOMY,4821,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3020.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3020.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3020.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3020.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3020.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3111.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3020.6,3111.22,
TRANSURETHRAL PROSTATECTOMY,4822,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3720.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3720.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3720.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3720.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3720.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3832.47,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3720.84,3832.47,
TRANSURETHRAL PROSTATECTOMY,4823,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6758.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6758.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6758.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6758.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6758.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6961.46,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6758.7,6961.46,
TRANSURETHRAL PROSTATECTOMY,4824,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11748.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11748.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11748.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11748.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11748.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12100.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11748.46,12100.91,
"PENIS, TESTES AND SCROTAL PROCEDURES",4831,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4123.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4123.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4123.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4123.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4123.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4246.78,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4123.09,4246.78,
"PENIS, TESTES AND SCROTAL PROCEDURES",4832,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5239.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5239.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5239.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5239.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5239.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5397.15,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5239.95,5397.15,
"PENIS, TESTES AND SCROTAL PROCEDURES",4833,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7862.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7862.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7862.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7862.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7862.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8098.5,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7862.62,8098.5,
"PENIS, TESTES AND SCROTAL PROCEDURES",4834,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14462.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14462.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14462.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,14462.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14462.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14895.94,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,14462.08,14895.94,
OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,4841,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4693.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4693.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4693.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4693.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4693.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4834,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4693.2,4834,
OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,4842,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5458.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5458.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5458.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5458.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5458.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5622.26,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5458.51,5622.26,
OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,4843,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6730.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6730.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6730.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6730.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6730.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6932.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6730.66,6932.58,
OTHER MALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,4844,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14902.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14902.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14902.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,14902.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14902.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15349.13,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,14902.06,15349.13,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",5001,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2892.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2892.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2892.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2892.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2892.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2979.78,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2892.99,2979.78,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",5002,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3031.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3031.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3031.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3031.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3031.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3121.96,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3031.03,3121.96,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",5003,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4558.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4558.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4558.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4558.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4558.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4694.78,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4558.04,4694.78,
"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",5004,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9130.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9130.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9130.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9130.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9130.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9404.38,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9130.46,9404.38,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,5011,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1960.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1960.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1960.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1960.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1960.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2018.98,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1960.17,2018.98,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,5012,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2542.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2542.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2542.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2542.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2542.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2619.16,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2542.87,2619.16,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,5013,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3819.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3819.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3819.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3819.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3819.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3934.29,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3819.7,3934.29,
MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,5014,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7604.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7604.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7604.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7604.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7604.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7833.03,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7604.88,7833.03,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES",5101,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5079.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5079.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5079.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5079.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5079.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5232.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5079.63,5232.02,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES",5102,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6020.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6020.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6020.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6020.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6020.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6201.33,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6020.71,6201.33,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES",5103,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10577.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10577.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10577.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10577.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10577.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10894.64,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10577.32,10894.64,
"PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND OTHER RADICAL GYNECOLOGICAL PROCEDURES",5104,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19880.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19880.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19880.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,19880.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19880.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20476.73,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,19880.32,20476.73,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY,5111,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5268.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5268.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5268.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5268.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5268.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5426.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5268.71,5426.77,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY,5112,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6415.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6415.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6415.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6415.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6415.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6607.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6415.41,6607.87,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY,5113,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9561.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9561.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9561.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9561.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9561.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9848.68,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9561.82,9848.68,
UTERINE AND ADNEXA PROCEDURES FOR OVARIAN AND ADNEXAL MALIGNANCY,5114,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18942.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18942.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18942.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18942.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18942.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19511.12,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18942.83,19511.12,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY,5121,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5079.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5079.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5079.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5079.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5079.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5232.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5079.63,5232.02,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY,5122,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5718.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5718.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5718.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5718.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5718.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5889.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5718.4,5889.95,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY,5123,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9584.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9584.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9584.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9584.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9584.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9871.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9584.11,9871.63,
UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY,5124,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16756.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16756.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16756.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16756.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16756.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17258.88,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16756.19,17258.88,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,5131,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3783.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3783.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3783.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3783.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3783.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3896.52,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3783.03,3896.52,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,5132,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4496.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4496.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4496.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4496.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4496.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4631.1,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4496.21,4631.1,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,5133,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7345.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7345.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7345.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7345.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7345.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7566.08,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7345.71,7566.08,
UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,5134,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12909.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12909.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12909.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12909.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12909.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13297.19,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12909.9,13297.19,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,5141,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3174.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3174.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3174.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3174.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3174.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3269.69,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3174.45,3269.69,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,5142,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4846.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4846.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4846.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4846.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4846.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4991.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4846.33,4991.72,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,5143,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7495.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7495.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7495.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7495.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7495.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7720.84,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7495.97,7720.84,
FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,5144,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19959.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19959.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19959.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,19959.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19959.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20558.56,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,19959.76,20558.56,
DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,5171,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2937.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2937.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2937.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2937.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2937.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3025.32,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2937.2,3025.32,
DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,5172,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3603.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3603.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3603.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3603.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3603.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3711.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3603.66,3711.77,
DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,5173,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5722.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5722.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5722.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5722.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5722.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5894.4,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5722.71,5894.4,
DILATION AND CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,5174,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10084.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10084.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10084.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10084.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10084.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10387.39,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10084.85,10387.39,
OTHER FEMALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,5181,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3500.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3500.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3500.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3500.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3500.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3605.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3500.85,3605.87,
OTHER FEMALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,5182,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4994.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4994.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4994.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4994.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4994.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5143.9,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4994.08,5143.9,
OTHER FEMALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,5183,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8771.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8771.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8771.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8771.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8771.71,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9034.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8771.71,9034.87,
OTHER FEMALE REPRODUCTIVE SYSTEM AND RELATED PROCEDURES,5184,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18520.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18520.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18520.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18520.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18520.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19076.07,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18520.46,19076.07,
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA,5191,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3599.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3599.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3599.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3599.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3599.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3707.32,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3599.34,3707.32,
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA,5192,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4700.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4700.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4700.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4700.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4700.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4841.4,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4700.39,4841.4,
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA,5193,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8066.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8066.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8066.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8066.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8066.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8308.06,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8066.08,8308.06,
UTERINE AND ADNEXA PROCEDURES FOR LEIOMYOMA,5194,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15686.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15686.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15686.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15686.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15686.06,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16156.64,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15686.06,16156.64,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,5301,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2617.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2617.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2617.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2617.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2617.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2695.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2617.28,2695.8,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,5302,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3183.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3183.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3183.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3183.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3183.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3278.57,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3183.08,3278.57,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,5303,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4848.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4848.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4848.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4848.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4848.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4993.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4848.49,4993.95,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,5304,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8637.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8637.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8637.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8637.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8637.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8896.39,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8637.27,8896.39,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,5311,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1958.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1958.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1958.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1958.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1958.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2017.5,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1958.74,2017.5,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,5312,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2546.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2546.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2546.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2546.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2546.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2622.86,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2546.46,2622.86,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,5313,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4236.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4236.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4236.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4236.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4236.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4363.78,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4236.68,4363.78,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,5314,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7431.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7431.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7431.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7431.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7431.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7654.94,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7431.98,7654.94,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,5321,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1891.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1891.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1891.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1891.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1891.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1947.89,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1891.16,1947.89,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,5322,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2268.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2268.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2268.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2268.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2268.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2336.28,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2268.24,2336.28,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,5323,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3405.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3405.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3405.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3405.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3405.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3507.76,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3405.59,3507.76,
MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,5324,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6966.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6966.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6966.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6966.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6966.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7175.83,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6966.83,7175.83,
CESAREAN SECTION WITH STERILIZATION,5391,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2162.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2162.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2162.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2162.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2162.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2227.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2162.91,2227.8,
CESAREAN SECTION WITH STERILIZATION,5392,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2593.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2593.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2593.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2593.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2593.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2671.73,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2593.91,2671.73,
CESAREAN SECTION WITH STERILIZATION,5393,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4165.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4165.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4165.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4165.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4165.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4290.84,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4165.86,4290.84,
CESAREAN SECTION WITH STERILIZATION,5394,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10525.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10525.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10525.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10525.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10525.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10841.32,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10525.55,10841.32,
CESAREAN SECTION WITHOUT STERILIZATION,5401,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2135.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2135.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2135.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2135.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2135.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2199.29,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2135.23,2199.29,
CESAREAN SECTION WITHOUT STERILIZATION,5402,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2661.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2661.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2661.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2661.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2661.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2741.34,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2661.49,2741.34,
CESAREAN SECTION WITHOUT STERILIZATION,5403,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3653.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3653.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3653.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3653.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3653.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3763.23,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3653.62,3763.23,
CESAREAN SECTION WITHOUT STERILIZATION,5404,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7634.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7634.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7634.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7634.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7634.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7863.76,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7634.72,7863.76,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C,5411,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2137.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2137.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2137.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2137.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2137.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2201.88,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2137.75,2201.88,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C,5412,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2234.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2234.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2234.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2234.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2234.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2301.85,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2234.81,2301.85,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C,5413,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3050.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3050.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3050.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3050.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3050.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3141.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3050.08,3141.58,
VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C,5414,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5124.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5124.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5124.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5124.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5124.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5278.67,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5124.92,5278.67,
VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,5421,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1437.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1437.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1437.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1437.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1437.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1480.26,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1437.15,1480.26,
VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,5422,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1718.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1718.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1718.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1718.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1718.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1769.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1718.25,1769.8,
VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,5423,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2905.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2905.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2905.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2905.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2905.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2992.37,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2905.21,2992.37,
VAGINAL DELIVERY WITH O.R. PROCEDURE EXCEPT STERILIZATION AND/OR D&C,5424,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8951.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8951.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8951.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8951.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8951.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9220.36,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8951.81,9220.36,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",5431,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2018.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2018.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2018.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2018.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2018.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2078.96,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2018.41,2078.96,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",5432,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2548.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2548.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2548.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2548.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2548.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2625.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2548.98,2625.45,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",5433,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3849.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3849.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3849.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3849.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3849.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3964.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3849.17,3964.65,
"ABORTION WITH D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",5434,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9423.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9423.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9423.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9423.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9423.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9706.13,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9423.43,9706.13,
ANTEPARTUM WITH O.R. PROCEDURE,5471,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2679.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2679.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2679.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2679.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2679.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2759.85,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2679.47,2759.85,
ANTEPARTUM WITH O.R. PROCEDURE,5472,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3661.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3661.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3661.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3661.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3661.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3771.01,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3661.17,3771.01,
ANTEPARTUM WITH O.R. PROCEDURE,5473,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5990.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5990.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5990.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5990.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5990.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6169.86,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5990.16,6169.86,
ANTEPARTUM WITH O.R. PROCEDURE,5474,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10648.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10648.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10648.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10648.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10648.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10968.32,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10648.85,10968.32,
POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE,5481,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1832.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1832.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1832.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1832.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1832.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1887.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1832.92,1887.91,
POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE,5482,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3553.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3553.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3553.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3553.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3553.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3659.93,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3553.33,3659.93,
POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE,5483,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6034.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6034.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6034.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6034.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6034.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6215.03,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6034.01,6215.03,
POSTPARTUM AND POST ABORTION DIAGNOSIS WITH O.R. PROCEDURE,5484,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13597.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13597.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13597.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13597.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13597.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14005.11,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13597.2,14005.11,
VAGINAL DELIVERY,5601,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1268.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1268.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1268.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1268.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1268.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1306.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1268.56,1306.62,
VAGINAL DELIVERY,5602,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1438.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1438.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1438.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1438.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1438.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1481.74,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1438.59,1481.74,
VAGINAL DELIVERY,5603,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2050.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2050.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2050.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2050.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2050.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2111.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2050.04,2111.54,
VAGINAL DELIVERY,5604,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3925.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3925.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3925.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3925.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3925.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4042.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3925.02,4042.77,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,5611,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,995.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,995.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,995.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,995.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,995.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1025.23,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,995.36,1025.23,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,5612,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1563.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1563.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1563.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1563.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1563.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1610.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1563.32,1610.22,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,5613,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2603.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2603.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2603.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2603.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2603.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2682.1,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2603.98,2682.1,
POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT PROCEDURE,5614,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6217.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6217.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6217.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6217.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6217.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6404.23,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6217.7,6404.23,
"ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",5641,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1216.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1216.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1216.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1216.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1216.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1253.3,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1216.8,1253.3,
"ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",5642,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1676.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1676.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1676.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1676.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1676.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1726.85,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1676.55,1726.85,
"ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",5643,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2693.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2693.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2693.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2693.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2693.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2774.66,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2693.85,2774.66,
"ABORTION WITHOUT D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",5644,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9075.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9075.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9075.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9075.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9075.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9348.1,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9075.82,9348.1,
ANTEPARTUM WITHOUT O.R. PROCEDURE,5661,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1075.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1075.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1075.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1075.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1075.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1107.79,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1075.53,1107.79,
ANTEPARTUM WITHOUT O.R. PROCEDURE,5662,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1442.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1442.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1442.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1442.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1442.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1486.19,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1442.9,1486.19,
ANTEPARTUM WITHOUT O.R. PROCEDURE,5663,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2284.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2284.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2284.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2284.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2284.41,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2352.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2284.41,2352.95,
ANTEPARTUM WITHOUT O.R. PROCEDURE,5664,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4736.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4736.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4736.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4736.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4736.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4878.43,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4736.34,4878.43,
"NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE",5801,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1144.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1144.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1144.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1144.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1144.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1178.51,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1144.18,1178.51,
"NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE",5802,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1693.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1693.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1693.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1693.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1693.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1744.25,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1693.45,1744.25,
"NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE",5803,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2748.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2748.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2748.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2748.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2748.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2830.57,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2748.13,2830.57,
"NEONATE, TRANSFERRED < 5 DAYS OLD, NOT BORN HERE",5804,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4313.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4313.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4313.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4313.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4313.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4443.01,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4313.6,4443.01,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",5811,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,384.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,384.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,384.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,384.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,384.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,396.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,384.99,396.54,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",5812,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,622.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,622.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,622.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,622.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,622.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,641.27,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,622.6,641.27,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",5813,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1067.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1067.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1067.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1067.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1067.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1099.28,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1067.26,1099.28,
"NEONATE, TRANSFERRED < 5 DAYS OLD, BORN HERE",5814,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1973.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1973.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1973.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1973.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1973.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2032.68,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1973.47,2032.68,
NEONATE WITH ECMO,5831,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,69493.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,69493.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,69493.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,69493.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,69493.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,71578.41,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,69493.6,71578.41,
NEONATE WITH ECMO,5832,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,95607.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,95607.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,95607.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,95607.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,95607.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,98475.29,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,95607.08,98475.29,
NEONATE WITH ECMO,5833,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,124517.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,124517.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,124517.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,124517.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,124517.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,128253.47,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,124517.93,128253.47,
NEONATE WITH ECMO,5834,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,192207.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,192207.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,192207.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,192207.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,192207.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,197973.59,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,192207.36,197973.59,
NEONATE BIRTH WEIGHT < 1500 GRAMS WITH MAJOR PROCEDURE,5881,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,61338.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,61338.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,61338.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,61338.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,61338.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,63178.15,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,61338.01,63178.15,
NEONATE BIRTH WEIGHT < 1500 GRAMS WITH MAJOR PROCEDURE,5882,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,71560.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,71560.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,71560.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,71560.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,71560.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,73707.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,71560.89,73707.72,
NEONATE BIRTH WEIGHT < 1500 GRAMS WITH MAJOR PROCEDURE,5883,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,81552.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,81552.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,81552.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,81552.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,81552.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,83999.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,81552.64,83999.22,
NEONATE BIRTH WEIGHT < 1500 GRAMS WITH MAJOR PROCEDURE,5884,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,125393.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,125393.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,125393.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,125393.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,125393.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,129155.4,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,125393.59,129155.4,
"NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL AGE <24 WEEKS, OR BIRTH WEIGHT 500-749 GRAMS WITH MAJOR ANOMALY OR WITHOUT LIFE SUSTAINING INTERVENTION",5891,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,48983.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,48983.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,48983.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,48983.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,48983.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,50453.36,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,48983.85,50453.36,
"NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL AGE <24 WEEKS, OR BIRTH WEIGHT 500-749 GRAMS WITH MAJOR ANOMALY OR WITHOUT LIFE SUSTAINING INTERVENTION",5892,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,47538.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,47538.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,47538.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,47538.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,47538.79,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,48964.96,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,47538.79,48964.96,
"NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL AGE <24 WEEKS, OR BIRTH WEIGHT 500-749 GRAMS WITH MAJOR ANOMALY OR WITHOUT LIFE SUSTAINING INTERVENTION",5893,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,46525.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,46525.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,46525.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,46525.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,46525.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,47921.59,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,46525.81,47921.59,
"NEONATE BIRTH WEIGHT < 500 GRAMS, OR BIRTH WEIGHT 500-999 GRAMS AND GESTATIONAL AGE <24 WEEKS, OR BIRTH WEIGHT 500-749 GRAMS WITH MAJOR ANOMALY OR WITHOUT LIFE SUSTAINING INTERVENTION",5894,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7264.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7264.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7264.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7264.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7264.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7482.03,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7264.11,7482.03,
NEONATE BIRTH WEIGHT 500-749 GRAMS WITHOUT MAJOR PROCEDURE,5911,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26951.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26951.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26951.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,26951.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26951.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,27760.31,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,26951.76,27760.31,
NEONATE BIRTH WEIGHT 500-749 GRAMS WITHOUT MAJOR PROCEDURE,5912,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,44835.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,44835.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,44835.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,44835.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,44835.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,46180.67,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,44835.6,46180.67,
NEONATE BIRTH WEIGHT 500-749 GRAMS WITHOUT MAJOR PROCEDURE,5913,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,59125.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,59125.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,59125.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,59125.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,59125.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,60898.89,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,59125.13,60898.89,
NEONATE BIRTH WEIGHT 500-749 GRAMS WITHOUT MAJOR PROCEDURE,5914,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,79657.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,79657.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,79657.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,79657.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,79657.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,82047.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,79657.89,82047.62,
NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE,5931,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9079.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9079.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9079.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9079.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9079.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9352.17,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9079.78,9352.17,
NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE,5932,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,41957.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,41957.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,41957.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,41957.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,41957.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,43216.07,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,41957.35,43216.07,
NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE,5933,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51226.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,51226.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,51226.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,51226.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,51226.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,52763.73,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,51226.92,52763.73,
NEONATE BIRTH WEIGHT 750-999 GRAMS WITHOUT MAJOR PROCEDURE,5934,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,73863.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,73863.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,73863.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,73863.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,73863.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,76079.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,73863.28,76079.18,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,6021,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9235.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9235.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9235.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9235.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9235.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9512.12,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9235.07,9512.12,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,6022,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,31113.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,31113.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,31113.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,31113.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,31113.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,32047.08,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,31113.67,32047.08,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,6023,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,38906.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,38906.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,38906.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,38906.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,38906.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,40073.75,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,38906.55,40073.75,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,6024,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,54849.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,54849.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,54849.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,54849.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,54849.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,56494.75,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,54849.27,56494.75,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,6031,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7756.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7756.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7756.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7756.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7756.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7989.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7756.94,7989.65,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,6032,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16826.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16826.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16826.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16826.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16826.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17331.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16826.65,17331.45,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,6033,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30178.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30178.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30178.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,30178.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30178.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,31083.68,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,30178.33,31083.68,
NEONATE BIRTH WEIGHT 1000-1249 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,6034,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,68321.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,68321.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,68321.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,68321.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,68321.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,70370.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,68321.02,70370.65,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,6071,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11914.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11914.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11914.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11914.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11914.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12271.97,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11914.53,12271.97,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,6072,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21491.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21491.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21491.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,21491.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21491.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22135.83,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,21491.09,22135.83,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,6073,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29098.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29098.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29098.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,29098.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29098.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29971.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,29098.49,29971.45,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION OR MAJOR ANOMALY,6074,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,42035.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,42035.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,42035.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,42035.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,42035.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,43296.41,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,42035.35,43296.41,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,6081,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6814.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6814.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6814.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6814.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6814.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7019.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6814.78,7019.22,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,6082,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15837.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15837.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15837.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15837.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15837.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16312.89,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15837.76,16312.89,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,6083,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21147.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21147.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21147.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,21147.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21147.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21781.5,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,21147.08,21781.5,
NEONATE BIRTH WEIGHT 1250-1499 GRAMS WITH OR WITHOUT SIGNIFICANT CONDITION,6084,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26558.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26558.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26558.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,26558.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26558.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,27354.89,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,26558.14,27354.89,
NEONATE BIRTH WEIGHT 1500-2499 GRAMS WITH MAJOR PROCEDURE,6091,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16135.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16135.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16135.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16135.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16135.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16619.09,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16135.04,16619.09,
NEONATE BIRTH WEIGHT 1500-2499 GRAMS WITH MAJOR PROCEDURE,6092,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16984.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16984.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16984.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16984.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16984.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17493.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16984.1,17493.62,
NEONATE BIRTH WEIGHT 1500-2499 GRAMS WITH MAJOR PROCEDURE,6093,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30783.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30783.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30783.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,30783.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30783.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,31707.19,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,30783.68,31707.19,
NEONATE BIRTH WEIGHT 1500-2499 GRAMS WITH MAJOR PROCEDURE,6094,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,82446.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,82446.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,82446.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,82446.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,82446.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,84920.03,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,82446.63,84920.03,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH MAJOR ANOMALY,6111,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6012.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6012.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6012.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6012.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6012.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6192.82,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6012.45,6192.82,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH MAJOR ANOMALY,6112,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11925.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11925.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11925.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11925.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11925.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12283.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11925.68,12283.45,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH MAJOR ANOMALY,6113,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21048.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21048.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21048.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,21048.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21048.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21679.68,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,21048.23,21679.68,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH MAJOR ANOMALY,6114,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34068.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,34068.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,34068.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,34068.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,34068.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,35090.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,34068.84,35090.91,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,6121,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9615.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9615.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9615.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9615.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9615.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9904.21,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9615.74,9904.21,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,6122,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14782,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14782,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14782,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,14782,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14782,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15225.46,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,14782,15225.46,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,6123,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18705.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18705.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18705.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18705.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18705.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19267.12,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18705.94,19267.12,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,6124,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30025.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30025.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30025.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,30025.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30025.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30926.33,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,30025.56,30926.33,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,6131,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7952.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7952.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7952.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7952.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7952.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8190.69,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7952.13,8190.69,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,6132,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10887.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10887.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10887.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10887.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10887.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11213.79,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10887.18,11213.79,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,6133,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20774.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20774.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20774.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,20774.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20774.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,21397.55,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,20774.32,21397.55,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,6134,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,34228.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,34228.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,34228.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,34228.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,34228.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,35255.67,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,34228.81,35255.67,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,6141,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4934.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4934.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4934.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4934.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4934.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5082.07,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4934.04,5082.07,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,6142,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9351.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9351.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9351.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9351.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9351.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9632.08,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9351.53,9632.08,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,6143,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16828.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16828.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16828.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16828.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16828.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17333.3,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16828.45,17333.3,
NEONATE BIRTH WEIGHT 1500-1999 GRAMS WITH OR WITHOUT OTHER SIGNIFICANT CONDITION,6144,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24513.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24513.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24513.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,24513.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24513.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25249.27,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,24513.85,25249.27,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH MAJOR ANOMALY,6211,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2346.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2346.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2346.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2346.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2346.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2417.37,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2346.96,2417.37,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH MAJOR ANOMALY,6212,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7203.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7203.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7203.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7203.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7203.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7419.46,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7203.36,7419.46,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH MAJOR ANOMALY,6213,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14214.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14214.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14214.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,14214.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14214.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14641.21,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,14214.76,14641.21,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH MAJOR ANOMALY,6214,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28840.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28840.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28840.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,28840.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28840.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29705.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,28840.4,29705.61,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,6221,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6197.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6197.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6197.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6197.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6197.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6383.5,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6197.57,6383.5,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,6222,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9206.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9206.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9206.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9206.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9206.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9482.5,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9206.31,9482.5,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,6223,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10610.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10610.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10610.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10610.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10610.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10928.7,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10610.39,10928.7,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,6224,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17941.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17941.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17941.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,17941.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17941.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18479.6,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,17941.36,18479.6,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,6231,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4564.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4564.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4564.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4564.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4564.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4701.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4564.51,4701.45,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,6232,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7626.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7626.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7626.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7626.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7626.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7855.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7626.81,7855.62,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,6233,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16149.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16149.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16149.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16149.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16149.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16634.27,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16149.77,16634.27,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,6234,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20206,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20206,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20206,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,20206,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20206,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20812.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,20206,20812.18,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,6251,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5277.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5277.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5277.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5277.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5277.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5436.03,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5277.69,5436.03,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,6252,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6618.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6618.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6618.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6618.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6618.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6817.43,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6618.87,6817.43,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,6253,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11737.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11737.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11737.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11737.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11737.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12089.81,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11737.68,12089.81,
NEONATE BIRTH WEIGHT 2000-2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,6254,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23982.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23982.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23982.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,23982.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23982.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24702.04,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,23982.56,24702.04,
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",6261,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,672.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,672.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,672.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,672.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,672.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,692.74,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,672.56,692.74,
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",6262,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,869.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,869.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,869.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,869.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,869.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,896.01,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,869.91,896.01,
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",6263,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2574.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2574.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2574.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2574.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2574.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2651.37,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2574.14,2651.37,
"NEONATE BIRTH WEIGHT 2000-2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",6264,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8313.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8313.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8313.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8313.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8313.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8562.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8313.39,8562.8,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR CARDIOVASCULAR PROCEDURE,6301,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11925.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11925.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11925.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11925.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11925.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12283.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11925.68,12283.45,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR CARDIOVASCULAR PROCEDURE,6302,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24994.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24994.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24994.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,24994.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24994.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25743.92,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,24994.1,25743.92,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR CARDIOVASCULAR PROCEDURE,6303,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,43677.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,43677.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,43677.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,43677.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,43677.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,44987.35,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,43677.04,44987.35,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR CARDIOVASCULAR PROCEDURE,6304,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,91470.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,91470.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,91470.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,91470.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,91470.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,94214.44,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,91470.33,94214.44,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE,6311,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3106.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3106.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3106.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3106.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3106.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3199.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3106.51,3199.71,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE,6312,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15783.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15783.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15783.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15783.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15783.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16257.35,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15783.84,16257.35,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE,6313,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24305,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24305,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24305,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,24305,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24305,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25034.15,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,24305,25034.15,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER MAJOR PROCEDURE,6314,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,80942.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,80942.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,80942.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,80942.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,80942.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,83370.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,80942.26,83370.53,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,6331,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,903.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,903.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,903.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,903.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,903.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,930.44,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,903.34,930.44,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,6332,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3465.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3465.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3465.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3465.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3465.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3569.96,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3465.98,3569.96,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,6333,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10547.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10547.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10547.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10547.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10547.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10863.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10547.48,10863.91,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH MAJOR ANOMALY,6334,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28549.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28549.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28549.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,28549.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28549.95,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29406.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,28549.95,29406.45,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,6341,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2626.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2626.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2626.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2626.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2626.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2705.79,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2626.98,2705.79,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,6342,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5558.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5558.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5558.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5558.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5558.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5725.19,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5558.44,5725.19,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,6343,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6346.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6346.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6346.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6346.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6346.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6536.41,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6346.03,6536.41,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH RESPIRATORY DISTRESS SYNDROME OR OTHER MAJOR RESPIRATORY CONDITION,6344,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16977.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16977.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16977.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16977.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16977.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17487.33,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16977.99,17487.33,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,6361,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2855.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2855.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2855.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2855.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2855.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2940.9,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2855.25,2940.9,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,6362,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4786.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4786.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4786.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4786.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4786.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4930.26,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4786.66,4930.26,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,6363,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9844.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9844.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9844.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9844.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9844.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10139.69,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9844.36,10139.69,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH CONGENITAL OR PERINATAL INFECTION,6364,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12765.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12765.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12765.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12765.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12765.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13147.98,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12765.03,13147.98,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,6391,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1777.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1777.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1777.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1777.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1777.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1830.52,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1777.2,1830.52,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,6392,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2831.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2831.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2831.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2831.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2831.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2916.84,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2831.88,2916.84,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,6393,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7967.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7967.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7967.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7967.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7967.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8206.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7967.59,8206.61,
NEONATE BIRTH WEIGHT > 2499 GRAMS WITH OTHER SIGNIFICANT CONDITION,6394,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12523.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12523.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12523.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12523.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12523.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12899.55,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12523.83,12899.55,
"NEONATE BIRTH WEIGHT > 2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",6401,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,409.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,409.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,409.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,409.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,409.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,421.35,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,409.07,421.35,
"NEONATE BIRTH WEIGHT > 2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",6402,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,586.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,586.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,586.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,586.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,586.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,603.88,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,586.29,603.88,
"NEONATE BIRTH WEIGHT > 2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",6403,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1341.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1341.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1341.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1341.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1341.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1381.41,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1341.17,1381.41,
"NEONATE BIRTH WEIGHT > 2499 GRAMS, NORMAL NEWBORN OR NEONATE WITH OTHER PROBLEM",6404,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7605.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7605.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7605.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7605.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7605.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7833.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7605.6,7833.77,
SPLENIC PROCEDURES,6501,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5264.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5264.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5264.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5264.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5264.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5421.96,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5264.03,5421.96,
SPLENIC PROCEDURES,6502,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7021.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7021.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7021.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7021.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7021.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7231.74,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7021.11,7231.74,
SPLENIC PROCEDURES,6503,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9909.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9909.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9909.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9909.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9909.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10206.34,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9909.07,10206.34,
SPLENIC PROCEDURES,6504,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17172.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17172.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17172.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,17172.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17172.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17688,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,17172.82,17688,
OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS,6511,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4407.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4407.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4407.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4407.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4407.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4539.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4407.42,4539.65,
OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS,6512,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6236.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6236.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6236.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6236.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6236.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6423.11,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6236.03,6423.11,
OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS,6513,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9181.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9181.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9181.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9181.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9181.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9457.32,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9181.87,9457.32,
OTHER PROCEDURES OF BLOOD AND BLOOD-FORMING ORGANS,6514,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19712.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19712.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19712.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,19712.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19712.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20304.2,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,19712.81,20304.2,
MAJOR HEMATOLOGIC OR IMMUNOLOGIC DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION,6601,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2790.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2790.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2790.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2790.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2790.54,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2874.26,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2790.54,2874.26,
MAJOR HEMATOLOGIC OR IMMUNOLOGIC DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION,6602,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3118.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3118.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3118.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3118.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3118.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3211.93,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3118.38,3211.93,
MAJOR HEMATOLOGIC OR IMMUNOLOGIC DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION,6603,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4919.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4919.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4919.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4919.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4919.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5066.89,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4919.31,5066.89,
MAJOR HEMATOLOGIC OR IMMUNOLOGIC DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION,6604,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12037.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12037.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12037.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12037.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12037.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12398.97,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12037.83,12398.97,
COAGULATION AND PLATELET DISORDERS,6611,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3179.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3179.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3179.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3179.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3179.85,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3275.24,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3179.85,3275.24,
COAGULATION AND PLATELET DISORDERS,6612,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4256.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4256.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4256.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4256.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4256.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4383.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4256.09,4383.77,
COAGULATION AND PLATELET DISORDERS,6613,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5277.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5277.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5277.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5277.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5277.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5435.66,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5277.34,5435.66,
COAGULATION AND PLATELET DISORDERS,6614,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10111.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10111.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10111.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10111.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10111.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10414.42,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10111.09,10414.42,
SICKLE CELL ANEMIA CRISIS,6621,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2129.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2129.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2129.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2129.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2129.12,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2193,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2129.12,2193,
SICKLE CELL ANEMIA CRISIS,6622,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2907.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2907.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2907.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2907.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2907.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2994.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2907.01,2994.22,
SICKLE CELL ANEMIA CRISIS,6623,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4449.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4449.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4449.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4449.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4449.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4583.34,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4449.84,4583.34,
SICKLE CELL ANEMIA CRISIS,6624,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9243.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9243.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9243.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9243.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9243.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9521,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9243.69,9521,
OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,6631,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2013.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2013.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2013.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2013.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2013.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2073.78,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2013.37,2073.78,
OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,6632,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2771.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2771.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2771.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2771.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2771.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2854.64,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2771.49,2854.64,
OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,6633,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3981.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3981.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3981.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3981.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3981.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4100.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3981.1,4100.53,
OTHER ANEMIA AND DISORDERS OF BLOOD AND BLOOD-FORMING ORGANS,6634,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7160.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7160.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7160.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7160.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7160.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7375.4,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7160.58,7375.4,
"MAJOR O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",6801,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6146.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6146.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6146.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6146.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6146.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6330.55,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6146.17,6330.55,
"MAJOR O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",6802,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8354.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8354.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8354.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8354.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8354.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8605.37,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8354.73,8605.37,
"MAJOR O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",6803,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13438.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13438.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13438.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13438.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13438.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13841.83,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13438.67,13841.83,
"MAJOR O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",6804,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28815.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28815.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28815.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,28815.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28815.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29680.06,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,28815.59,29680.06,
"OTHER  O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",6811,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4627.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4627.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4627.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4627.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4627.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4766.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4627.78,4766.61,
"OTHER  O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",6812,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6259.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6259.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6259.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6259.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6259.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6447.55,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6259.76,6447.55,
"OTHER  O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",6813,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10604.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10604.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10604.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10604.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10604.64,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10922.78,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10604.64,10922.78,
"OTHER  O.R. PROCEDURES FOR LYMPHATIC, HEMATOPOIETIC OR OTHER NEOPLASMS",6814,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26256.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26256.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26256.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,26256.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26256.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,27044.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,26256.91,27044.61,
ACUTE LEUKEMIA,6901,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4875.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4875.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4875.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4875.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4875.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5021.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4875.45,5021.71,
ACUTE LEUKEMIA,6902,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8685.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8685.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8685.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8685.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8685.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8946,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8685.44,8946,
ACUTE LEUKEMIA,6903,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15062.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15062.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15062.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15062.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15062.75,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15514.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15062.75,15514.63,
ACUTE LEUKEMIA,6904,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26010.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26010.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26010.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,26010.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26010.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26790.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,26010.31,26790.62,
"LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA",6911,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4062.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4062.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4062.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4062.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4062.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4184.21,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4062.34,4184.21,
"LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA",6912,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5222.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5222.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5222.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5222.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5222.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5379.01,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5222.34,5379.01,
"LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA",6913,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7746.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7746.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7746.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7746.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7746.51,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7978.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7746.51,7978.91,
"LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA",6914,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15227.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15227.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15227.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15227.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15227.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15684.2,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15227.38,15684.2,
RADIOTHERAPY,6921,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4389.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4389.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4389.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4389.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4389.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4521.51,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4389.81,4521.51,
RADIOTHERAPY,6922,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6115.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6115.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6115.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6115.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6115.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6299.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6115.97,6299.45,
RADIOTHERAPY,6923,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9185.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9185.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9185.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9185.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9185.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9461.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9185.46,9461.02,
RADIOTHERAPY,6924,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13075.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13075.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13075.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13075.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13075.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13467.51,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13075.25,13467.51,
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,6941,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2785.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2785.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2785.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2785.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2785.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2868.7,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2785.15,2868.7,
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,6942,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3393.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3393.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3393.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3393.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3393.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3495.17,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3393.37,3495.17,
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,6943,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5153.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5153.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5153.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5153.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5153.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5308.29,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5153.68,5308.29,
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,6944,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9499.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9499.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9499.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9499.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9499.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9784.25,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9499.27,9784.25,
CHEMOTHERAPY FOR ACUTE LEUKEMIA,6951,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2103.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2103.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2103.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2103.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2103.96,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2167.08,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2103.96,2167.08,
CHEMOTHERAPY FOR ACUTE LEUKEMIA,6952,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3541.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3541.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3541.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3541.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3541.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3647.34,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3541.11,3647.34,
CHEMOTHERAPY FOR ACUTE LEUKEMIA,6953,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8425.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8425.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8425.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8425.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8425.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8678.68,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8425.91,8678.68,
CHEMOTHERAPY FOR ACUTE LEUKEMIA,6954,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23049.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23049.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23049.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,23049.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23049.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23741.24,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,23049.74,23741.24,
OTHER CHEMOTHERAPY,6961,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2943.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2943.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2943.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2943.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2943.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3031.99,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2943.68,3031.99,
OTHER CHEMOTHERAPY,6962,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3593.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3593.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3593.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3593.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3593.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3701.03,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3593.23,3701.03,
OTHER CHEMOTHERAPY,6963,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5814.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5814.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5814.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5814.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5814.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5989.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5814.74,5989.18,
OTHER CHEMOTHERAPY,6964,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12651.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12651.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12651.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12651.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12651.8,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13031.35,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12651.8,13031.35,
INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,7101,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4193.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4193.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4193.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4193.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4193.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4318.98,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4193.18,4318.98,
INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,7102,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5897.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5897.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5897.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5897.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5897.78,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6074.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5897.78,6074.71,
INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,7103,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9662.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9662.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9662.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9662.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9662.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9952.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9662.83,9952.72,
INFECTIOUS AND PARASITIC DISEASES INCLUDING HIV WITH O.R. PROCEDURE,7104,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17750.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17750.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17750.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,17750.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17750.48,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18282.99,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,17750.48,18282.99,
"POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE",7111,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4179.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4179.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4179.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4179.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4179.16,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4304.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4179.16,4304.54,
"POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE",7112,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5598.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5598.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5598.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5598.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5598.34,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5766.29,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5598.34,5766.29,
"POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE",7113,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9346.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9346.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9346.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9346.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9346.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9626.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9346.14,9626.53,
"POST-OPERATIVE, POST-TRAUMA, OTHER DEVICE INFECTIONS WITH O.R. PROCEDURE",7114,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17063.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17063.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17063.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,17063.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17063.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17575.07,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,17063.18,17575.07,
SEPTICEMIA AND DISSEMINATED INFECTIONS,7201,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2284.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2284.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2284.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2284.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2284.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2353.32,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2284.77,2353.32,
SEPTICEMIA AND DISSEMINATED INFECTIONS,7202,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2895.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2895.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2895.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2895.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2895.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2982.74,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2895.87,2982.74,
SEPTICEMIA AND DISSEMINATED INFECTIONS,7203,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4519.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4519.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4519.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4519.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4519.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4654.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4519.22,4654.8,
SEPTICEMIA AND DISSEMINATED INFECTIONS,7204,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8856.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8856.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8856.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8856.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8856.91,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9122.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8856.91,9122.61,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",7211,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2283.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2283.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2283.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2283.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2283.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2351.83,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2283.33,2351.83,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",7212,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3098.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3098.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3098.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3098.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3098.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3191.56,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3098.61,3191.56,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",7213,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4955.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4955.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4955.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4955.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4955.25,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5103.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4955.25,5103.91,
"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",7214,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8816.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8816.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8816.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8816.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8816.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9080.78,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8816.29,9080.78,
FEVER AND INFLAMMATORY CONDITIONS,7221,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1653.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1653.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1653.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1653.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1653.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1702.78,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1653.19,1702.78,
FEVER AND INFLAMMATORY CONDITIONS,7222,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2299.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2299.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2299.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2299.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2299.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2368.13,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2299.15,2368.13,
FEVER AND INFLAMMATORY CONDITIONS,7223,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3290.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3290.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3290.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3290.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3290.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3389.28,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3290.56,3389.28,
FEVER AND INFLAMMATORY CONDITIONS,7224,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5452.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5452.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5452.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5452.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5452.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5615.97,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5452.4,5615.97,
VIRAL ILLNESS,7231,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1606.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1606.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1606.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1606.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1606.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1655.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1606.82,1655.02,
VIRAL ILLNESS,7232,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2163.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2163.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2163.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2163.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2163.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2228.17,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2163.27,2228.17,
VIRAL ILLNESS,7233,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3452.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3452.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3452.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3452.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3452.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3556.26,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3452.68,3556.26,
VIRAL ILLNESS,7234,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8696.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8696.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8696.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8696.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8696.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8957.85,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8696.94,8957.85,
OTHER INFECTIOUS AND PARASITIC DISEASES,7241,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2348.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2348.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2348.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2348.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2348.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2419.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2348.76,2419.22,
OTHER INFECTIOUS AND PARASITIC DISEASES,7242,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2832.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2832.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2832.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2832.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2832.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2917.21,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2832.24,2917.21,
OTHER INFECTIOUS AND PARASITIC DISEASES,7243,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4646.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4646.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4646.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4646.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4646.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4785.49,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4646.11,4785.49,
OTHER INFECTIOUS AND PARASITIC DISEASES,7244,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9865.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9865.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9865.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9865.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9865.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10161.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9865.93,10161.91,
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE,7401,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4106.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4106.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4106.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4106.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4106.19,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4229.38,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4106.19,4229.38,
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE,7402,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4612.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4612.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4612.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4612.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4612.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4750.69,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4612.32,4750.69,
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE,7403,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10448.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10448.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10448.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10448.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10448.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10762.46,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10448.99,10762.46,
MENTAL ILLNESS DIAGNOSIS WITH O.R. PROCEDURE,7404,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26149.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26149.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26149.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,26149.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26149.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26933.91,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,26149.43,26933.91,
SCHIZOPHRENIA,7501,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2383.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2383.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2383.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2383.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2383.27,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2454.76,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2383.27,2454.76,
SCHIZOPHRENIA,7502,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3060.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3060.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3060.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3060.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3060.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3151.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3060.14,3151.95,
SCHIZOPHRENIA,7503,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5115.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5115.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5115.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5115.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5115.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5269.04,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5115.57,5269.04,
SCHIZOPHRENIA,7504,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10713.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10713.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10713.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10713.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10713.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11034.96,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10713.55,11034.96,
MAJOR DEPRESSIVE DISORDERS AND OTHER OR UNSPECIFIED PSYCHOSES,7511,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1398.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1398.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1398.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1398.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1398.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1440.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1398.69,1440.65,
MAJOR DEPRESSIVE DISORDERS AND OTHER OR UNSPECIFIED PSYCHOSES,7512,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1981.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1981.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1981.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1981.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1981.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2041.19,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1981.74,2041.19,
MAJOR DEPRESSIVE DISORDERS AND OTHER OR UNSPECIFIED PSYCHOSES,7513,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3866.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3866.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3866.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3866.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3866.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3982.42,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3866.43,3982.42,
MAJOR DEPRESSIVE DISORDERS AND OTHER OR UNSPECIFIED PSYCHOSES,7514,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7984.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7984.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7984.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7984.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7984.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8224.39,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7984.84,8224.39,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,7521,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1177.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1177.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1177.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1177.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1177.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1212.94,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1177.61,1212.94,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,7522,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1708.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1708.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1708.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1708.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1708.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1759.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1708.55,1759.8,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,7523,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4881.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4881.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4881.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4881.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4881.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5028.01,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4881.56,5028.01,
DISORDERS OF PERSONALITY AND IMPULSE CONTROL,7524,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9060.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9060.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9060.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9060.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9060.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9332.55,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9060.73,9332.55,
BIPOLAR DISORDERS,7531,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1561.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1561.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1561.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1561.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1561.17,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1608,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1561.17,1608,
BIPOLAR DISORDERS,7532,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2184.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2184.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2184.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2184.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2184.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2250.39,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2184.84,2250.39,
BIPOLAR DISORDERS,7533,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4269.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4269.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4269.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4269.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4269.39,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4397.47,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4269.39,4397.47,
BIPOLAR DISORDERS,7534,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7651.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7651.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7651.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7651.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7651.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7881.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7651.97,7881.53,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,7541,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1210.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1210.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1210.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1210.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1210.33,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1246.64,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1210.33,1246.64,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,7542,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1701.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1701.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1701.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1701.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1701.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1752.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1701.72,1752.77,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,7543,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3053.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3053.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3053.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3053.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3053.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3145.28,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3053.67,3145.28,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,7544,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7352.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7352.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7352.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7352.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7352.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7573.48,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7352.9,7573.48,
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,7551,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1164.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1164.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1164.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1164.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1164.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1199.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1164.67,1199.61,
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,7552,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1746.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1746.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1746.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1746.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1746.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1798.68,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1746.29,1798.68,
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,7553,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2914.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2914.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2914.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2914.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2914.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3001.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2914.2,3001.62,
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,7554,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4439.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4439.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4439.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4439.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4439.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4572.6,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4439.42,4572.6,
ACUTE ANXIETY AND DELIRIUM STATES,7561,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1946.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1946.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1946.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1946.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1946.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2004.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1946.15,2004.54,
ACUTE ANXIETY AND DELIRIUM STATES,7562,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2444.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2444.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2444.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2444.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2444.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2517.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2444.38,2517.71,
ACUTE ANXIETY AND DELIRIUM STATES,7563,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2721.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2721.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2721.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2721.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2721.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2803.17,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2721.52,2803.17,
ACUTE ANXIETY AND DELIRIUM STATES,7564,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6508.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6508.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6508.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6508.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6508.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6703.39,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6508.15,6703.39,
ORGANIC MENTAL HEALTH DISTURBANCES,7571,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2032.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2032.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2032.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2032.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2032.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2093.03,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2032.07,2093.03,
ORGANIC MENTAL HEALTH DISTURBANCES,7572,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2923.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2923.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2923.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2923.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2923.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3011.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2923.9,3011.62,
ORGANIC MENTAL HEALTH DISTURBANCES,7573,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4941.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4941.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4941.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4941.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4941.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5089.47,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4941.23,5089.47,
ORGANIC MENTAL HEALTH DISTURBANCES,7574,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9792.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9792.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9792.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9792.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9792.6,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10086.38,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9792.6,10086.38,
BEHAVIORAL DISORDERS,7581,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1525.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1525.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1525.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1525.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1525.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1571.35,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1525.58,1571.35,
BEHAVIORAL DISORDERS,7582,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1883.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1883.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1883.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1883.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1883.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1940.12,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1883.61,1940.12,
BEHAVIORAL DISORDERS,7583,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3616.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3616.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3616.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3616.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3616.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3724.73,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3616.24,3724.73,
BEHAVIORAL DISORDERS,7584,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19125.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19125.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19125.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,19125.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19125.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19699.2,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,19125.44,19699.2,
EATING DISORDERS,7591,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3685.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3685.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3685.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3685.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3685.62,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3796.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3685.62,3796.18,
EATING DISORDERS,7592,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4528.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4528.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4528.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4528.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4528.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4664.79,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4528.92,4664.79,
EATING DISORDERS,7593,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6634.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6634.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6634.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6634.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6634.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6833.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6634.68,6833.72,
EATING DISORDERS,7594,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24554.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24554.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24554.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,24554.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24554.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25291.48,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,24554.83,25291.48,
OTHER MENTAL HEALTH DISORDERS,7601,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1903.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1903.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1903.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1903.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1903.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1960.48,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1903.38,1960.48,
OTHER MENTAL HEALTH DISORDERS,7602,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2845.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2845.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2845.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2845.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2845.18,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2930.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2845.18,2930.54,
OTHER MENTAL HEALTH DISORDERS,7603,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4424.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4424.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4424.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4424.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4424.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4557.05,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4424.32,4557.05,
OTHER MENTAL HEALTH DISORDERS,7604,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9143.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9143.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9143.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9143.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9143.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9417.7,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9143.4,9417.7,
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",7701,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1063.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1063.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1063.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1063.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1063.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1095.57,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1063.66,1095.57,
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",7702,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1566.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1566.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1566.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1566.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1566.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1613.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1566.2,1613.18,
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",7703,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2611.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2611.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2611.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2611.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2611.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2689.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2611.53,2689.87,
"DRUG AND ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",7704,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5579.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5579.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5579.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5579.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5579.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5747.04,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5579.65,5747.04,
ALCOHOL AND DRUG DEPENDENCE WITH REHABILITATION AND/OR DETOXIFICATION THERAPY,7721,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1768.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1768.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1768.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1768.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1768.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1822.01,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1768.94,1822.01,
ALCOHOL AND DRUG DEPENDENCE WITH REHABILITATION AND/OR DETOXIFICATION THERAPY,7722,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2472.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2472.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2472.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2472.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2472.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2546.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2472.05,2546.22,
ALCOHOL AND DRUG DEPENDENCE WITH REHABILITATION AND/OR DETOXIFICATION THERAPY,7723,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3150.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3150.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3150.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3150.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3150.01,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3244.51,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3150.01,3244.51,
ALCOHOL AND DRUG DEPENDENCE WITH REHABILITATION AND/OR DETOXIFICATION THERAPY,7724,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7796.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7796.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7796.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7796.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7796.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8030.74,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7796.84,8030.74,
OPIOID ABUSE AND DEPENDENCE,7731,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1096.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1096.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1096.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1096.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1096.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1129.64,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1096.73,1129.64,
OPIOID ABUSE AND DEPENDENCE,7732,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1628.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1628.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1628.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1628.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1628.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1676.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1628.03,1676.87,
OPIOID ABUSE AND DEPENDENCE,7733,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3218.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3218.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3218.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3218.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3218.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3314.86,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3218.31,3314.86,
OPIOID ABUSE AND DEPENDENCE,7734,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7585.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7585.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7585.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7585.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7585.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7813.04,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7585.47,7813.04,
COCAINE ABUSE AND DEPENDENCE,7741,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1398.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1398.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1398.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1398.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1398.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1440.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1398.69,1440.65,
COCAINE ABUSE AND DEPENDENCE,7742,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1634.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1634.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1634.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1634.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1634.5,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1683.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1634.5,1683.53,
COCAINE ABUSE AND DEPENDENCE,7743,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3082.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3082.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3082.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3082.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3082.07,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3174.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3082.07,3174.53,
COCAINE ABUSE AND DEPENDENCE,7744,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7327.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7327.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7327.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7327.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7327.38,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7547.2,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7327.38,7547.2,
ALCOHOL ABUSE AND DEPENDENCE,7751,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1523.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1523.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1523.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1523.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1523.42,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1569.12,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1523.42,1569.12,
ALCOHOL ABUSE AND DEPENDENCE,7752,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2056.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2056.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2056.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2056.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2056.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2117.84,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2056.15,2117.84,
ALCOHOL ABUSE AND DEPENDENCE,7753,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3700.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3700.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3700.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3700.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3700.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3811.36,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3700.35,3811.36,
ALCOHOL ABUSE AND DEPENDENCE,7754,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8696.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8696.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8696.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8696.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8696.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8957.48,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8696.59,8957.48,
OTHER DRUG ABUSE AND DEPENDENCE,7761,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1669.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1669.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1669.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1669.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1669.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1719.82,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1669.72,1719.82,
OTHER DRUG ABUSE AND DEPENDENCE,7762,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1849.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1849.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1849.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1849.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1849.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1904.57,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1849.1,1904.57,
OTHER DRUG ABUSE AND DEPENDENCE,7763,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3271.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3271.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3271.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3271.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3271.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3369.28,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3271.15,3369.28,
OTHER DRUG ABUSE AND DEPENDENCE,7764,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6486.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6486.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6486.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6486.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6486.22,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6680.81,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6486.22,6680.81,
EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,7921,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5290.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5290.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5290.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5290.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5290.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5449.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5290.99,5449.72,
EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,7922,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6764.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6764.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6764.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6764.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6764.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6967.01,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6764.09,6967.01,
EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,7923,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10201.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10201.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10201.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10201.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10201.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10507.72,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10201.67,10507.72,
EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,7924,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19918.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19918.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19918.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,19918.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19918.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20515.98,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,19918.43,20515.98,
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,7931,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4059.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4059.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4059.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4059.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4059.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4181.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4059.82,4181.61,
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,7932,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5471.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5471.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5471.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5471.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5471.09,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5635.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5471.09,5635.22,
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,7933,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8367.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8367.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8367.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8367.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8367.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8618.33,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8367.31,8618.33,
MODERATELY EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,7934,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16452.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16452.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16452.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16452.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16452.45,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16946.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16452.45,16946.02,
NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,7941,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3293.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3293.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3293.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3293.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3293.44,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3392.24,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3293.44,3392.24,
NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,7942,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4340.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4340.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4340.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4340.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4340.92,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4471.15,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4340.92,4471.15,
NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,7943,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6523.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6523.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6523.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6523.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6523.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6719.69,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6523.97,6719.69,
NON-EXTENSIVE O.R. PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,7944,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12310.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12310.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12310.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12310.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12310.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12679.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12310.31,12679.62,
HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,8101,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1935.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1935.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1935.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1935.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1935.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1993.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1935.73,1993.8,
HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,8102,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2586.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2586.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2586.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2586.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2586.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2663.96,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2586.37,2663.96,
HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,8103,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4182.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4182.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4182.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4182.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4182.4,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4307.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4182.4,4307.87,
HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,8104,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8783.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8783.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8783.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8783.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8783.94,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9047.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8783.94,9047.45,
ALLERGIC REACTIONS,8111,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1356.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1356.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1356.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1356.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1356.63,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1397.33,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1356.63,1397.33,
ALLERGIC REACTIONS,8112,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2026.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2026.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2026.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2026.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2026.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2087.1,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2026.32,2087.1,
ALLERGIC REACTIONS,8113,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4015.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4015.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4015.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4015.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4015.97,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4136.44,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4015.97,4136.44,
ALLERGIC REACTIONS,8114,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8407.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8407.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8407.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8407.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8407.57,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8659.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8407.57,8659.8,
POISONING OF MEDICINAL AGENTS,8121,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1481.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1481.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1481.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1481.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1481.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1525.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1481.36,1525.8,
POISONING OF MEDICINAL AGENTS,8122,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2073.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2073.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2073.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2073.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2073.05,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2135.24,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2073.05,2135.24,
POISONING OF MEDICINAL AGENTS,8123,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3182.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3182.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3182.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3182.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3182.36,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3277.83,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3182.36,3277.83,
POISONING OF MEDICINAL AGENTS,8124,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6369.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6369.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6369.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6369.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6369.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6560.85,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6369.76,6560.85,
OTHER COMPLICATIONS OF TREATMENT,8131,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2371.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2371.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2371.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2371.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2371.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2442.18,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2371.04,2442.18,
OTHER COMPLICATIONS OF TREATMENT,8132,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2916.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2916.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2916.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2916.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2916.72,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3004.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2916.72,3004.22,
OTHER COMPLICATIONS OF TREATMENT,8133,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4315.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4315.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4315.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4315.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4315.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4445.23,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4315.76,4445.23,
OTHER COMPLICATIONS OF TREATMENT,8134,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8176.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8176.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8176.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8176.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8176.08,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8421.36,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8176.08,8421.36,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES",8151,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1764.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1764.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1764.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1764.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1764.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1817.93,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1764.98,1817.93,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES",8152,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2323.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2323.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2323.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2323.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2323.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2393.3,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2323.59,2393.3,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES",8153,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4157.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4157.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4157.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4157.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4157.24,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4281.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4157.24,4281.95,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES",8154,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9275.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9275.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9275.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9275.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9275.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9553.96,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9275.69,9553.96,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,8161,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2496.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2496.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2496.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2496.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2496.14,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2571.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2496.14,2571.02,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,8162,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2627.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2627.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2627.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2627.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2627.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2706.53,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2627.7,2706.53,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,8163,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3228.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3228.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3228.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3228.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3228.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3325.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3228.37,3325.22,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,8164,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6282.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6282.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6282.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6282.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6282.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6471.25,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6282.76,6471.25,
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,8171,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1464.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1464.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1464.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1464.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1464.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1508.4,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1464.47,1508.4,
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,8172,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1924.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1924.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1924.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1924.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1924.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1982.32,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1924.59,1982.32,
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,8173,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3343.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3343.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3343.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3343.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3343.76,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3444.07,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3343.76,3444.07,
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,8174,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6898.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6898.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6898.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6898.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6898.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7105.86,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6898.89,7105.86,
EXTENSIVE THIRD DEGREE BURNS WITH SKIN GRAFT,8411,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19589.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19589.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19589.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,19589.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19589.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20176.83,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,19589.15,20176.83,
EXTENSIVE THIRD DEGREE BURNS WITH SKIN GRAFT,8412,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,19589.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19589.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19589.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,19589.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,19589.15,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,20176.83,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,19589.15,20176.83,
EXTENSIVE THIRD DEGREE BURNS WITH SKIN GRAFT,8413,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28871.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28871.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28871.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,28871.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,28871.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29737.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,28871.31,29737.45,
EXTENSIVE THIRD DEGREE BURNS WITH SKIN GRAFT,8414,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90217.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,90217.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,90217.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,90217.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,90217.23,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,92923.75,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,90217.23,92923.75,
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS,8421,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6158.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6158.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6158.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6158.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6158.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6342.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6158.03,6342.77,
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS,8422,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8982,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8982,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8982,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8982,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8982,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9251.46,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8982,9251.46,
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS,8423,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17060.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17060.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17060.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,17060.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17060.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17572.11,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,17060.3,17572.11,
BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE THIRD DEGREE BURNS,8424,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,46203.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,46203.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,46203.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,46203.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,46203.37,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,47589.47,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,46203.37,47589.47,
EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT,8431,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2360.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2360.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2360.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2360.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2360.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2431.81,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2360.98,2431.81,
EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT,8432,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3645,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3645,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3645,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3645,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3645,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3754.35,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3645,3754.35,
EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT,8433,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5280.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5280.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5280.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5280.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5280.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5438.62,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5280.21,5438.62,
EXTENSIVE THIRD DEGREE BURNS WITHOUT SKIN GRAFT,8434,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10370.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10370.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10370.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10370.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10370.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10682.11,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10370.98,10682.11,
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT,8441,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1942.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1942.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1942.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1942.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1942.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2000.47,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1942.2,2000.47,
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT,8442,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3093.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3093.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3093.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3093.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3093.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3186.01,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3093.21,3186.01,
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT,8443,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4921.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4921.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4921.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4921.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4921.46,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5069.11,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4921.46,5069.11,
PARTIAL THICKNESS BURNS WITHOUT SKIN GRAFT,8444,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11539.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11539.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11539.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11539.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11539.61,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11885.8,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11539.61,11885.8,
"PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES",8501,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7070,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7070,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7070,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7070,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7070,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7282.1,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7070,7282.1,
"PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES",8502,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9554.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9554.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9554.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9554.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9554.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9841.64,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9554.99,9841.64,
"PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES",8503,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12785.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12785.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12785.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12785.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12785.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13169.09,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12785.52,13169.09,
"PROCEDURE WITH DIAGNOSIS OF REHABILITATION, AFTERCARE OR OTHER CONTACT WITH HEALTH SERVICES",8504,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,29751.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29751.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29751.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,29751.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,29751.29,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,30643.82,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,29751.29,30643.82,
GENDER RELATED PROCEDURES,8511,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8493.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8493.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8493.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8493.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8493.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8748.29,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8493.49,8748.29,
GENDER RELATED PROCEDURES,8512,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8670.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8670.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8670.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8670.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8670.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8930.82,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8670.7,8930.82,
GENDER RELATED PROCEDURES,8513,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13656.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13656.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13656.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13656.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13656.87,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,14066.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13656.87,14066.58,
GENDER RELATED PROCEDURES,8514,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,46902.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,46902.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,46902.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,46902.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,46902.89,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,48309.98,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,46902.89,48309.98,
REHABILITATION,8601,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4312.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4312.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4312.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4312.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4312.53,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4441.9,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4312.53,4441.9,
REHABILITATION,8602,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5513.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5513.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5513.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5513.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5513.86,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5679.28,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5513.86,5679.28,
REHABILITATION,8603,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6990.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6990.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6990.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6990.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6990.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7200.27,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6990.55,7200.27,
REHABILITATION,8604,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8725.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8725.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8725.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8725.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8725.7,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8987.47,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8725.7,8987.47,
"SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS",8611,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1912,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1912,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1912,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1912,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1912,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1969.37,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1912,1969.37,
"SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS",8612,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2515.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2515.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2515.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2515.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2515.55,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2591.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2515.55,2591.02,
"SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS",8613,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3784.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3784.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3784.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3784.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3784.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3898.37,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3784.83,3898.37,
"SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS",8614,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6203.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6203.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6203.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6203.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6203.32,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6389.42,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6203.32,6389.42,
OTHER AFTERCARE AND CONVALESCENCE,8621,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1958.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1958.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1958.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,1958.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,1958.02,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2016.76,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,1958.02,2016.76,
OTHER AFTERCARE AND CONVALESCENCE,8622,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3622.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3622.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3622.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3622.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3622.35,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3731.02,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3622.35,3731.02,
OTHER AFTERCARE AND CONVALESCENCE,8623,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3731.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3731.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3731.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3731.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3731.99,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3843.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3731.99,3843.95,
OTHER AFTERCARE AND CONVALESCENCE,8624,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3881.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3881.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3881.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3881.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3881.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3998.34,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3881.88,3998.34,
NEONATAL AFTERCARE,8631,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4765.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4765.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4765.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4765.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4765.81,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4908.79,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4765.81,4908.79,
NEONATAL AFTERCARE,8632,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9235.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9235.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9235.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9235.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9235.43,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9512.49,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9235.43,9512.49,
NEONATAL AFTERCARE,8633,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18135.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18135.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18135.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,18135.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18135.11,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18679.16,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,18135.11,18679.16,
NEONATAL AFTERCARE,8634,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35009.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,35009.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,35009.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,35009.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,35009.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,36059.49,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,35009.21,36059.49,
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,8901,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3221.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3221.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3221.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3221.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3221.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3318.56,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3221.9,3318.56,
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,8902,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3391.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3391.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3391.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3391.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3391.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3492.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3391.21,3492.95,
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,8903,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5798.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5798.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5798.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5798.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5798.56,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5972.52,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5798.56,5972.52,
HIV WITH MULTIPLE MAJOR HIV RELATED CONDITIONS,8904,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11972.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11972.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11972.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11972.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11972.77,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12331.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11972.77,12331.95,
HIV WITH MAJOR HIV RELATED CONDITION,8921,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2811.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2811.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2811.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2811.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2811.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2895.36,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2811.03,2895.36,
HIV WITH MAJOR HIV RELATED CONDITION,8922,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3346.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3346.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3346.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3346.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3346.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3446.67,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3346.28,3446.67,
HIV WITH MAJOR HIV RELATED CONDITION,8923,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4616.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4616.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4616.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4616.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4616.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4754.76,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4616.28,4754.76,
HIV WITH MAJOR HIV RELATED CONDITION,8924,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7725.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7725.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7725.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7725.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7725.31,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7957.06,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7725.31,7957.06,
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,8931,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3416.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3416.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3416.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3416.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3416.73,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3519.24,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3416.73,3519.24,
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,8932,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3638.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3638.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3638.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3638.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3638.52,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3747.68,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3638.52,3747.68,
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,8933,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4808.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4808.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4808.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4808.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4808.59,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4952.85,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4808.59,4952.85,
HIV WITH MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,8934,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7118.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7118.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7118.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7118.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7118.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7332.45,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7118.88,7332.45,
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS,8941,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2552.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2552.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2552.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,2552.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2552.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,2629.15,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,2552.58,2629.15,
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS,8942,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3131.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3131.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3131.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3131.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3131.68,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3225.63,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3131.68,3225.63,
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS,8943,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4382.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4382.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4382.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4382.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4382.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4513.73,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4382.26,4513.73,
HIV WITH ONE SIGNIFICANT HIV CONDITION OR WITHOUT SIGNIFICANT RELATED CONDITIONS,8944,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6903.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6903.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6903.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6903.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6903.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7110.3,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6903.2,7110.3,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,9101,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9764.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9764.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9764.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9764.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9764.2,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10057.13,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9764.2,10057.13,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,9102,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10277.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10277.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10277.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,10277.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10277.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,10586.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,10277.88,10586.22,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,9103,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17899.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17899.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17899.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,17899.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17899.66,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,18436.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,17899.66,18436.65,
CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,9104,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26692.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26692.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26692.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,26692.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,26692.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,27493.36,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,26692.58,27493.36,
EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,9111,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6865.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6865.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6865.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6865.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6865.82,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7071.79,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6865.82,7071.79,
EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,9112,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8479.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8479.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8479.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8479.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8479.47,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8733.85,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8479.47,8733.85,
EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,9113,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11621.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11621.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11621.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11621.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11621.21,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11969.84,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11621.21,11969.84,
EXTENSIVE ABDOMINAL OR THORACIC PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,9114,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25033.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25033.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25033.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,25033.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25033.28,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,25784.28,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,25033.28,25784.28,
MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,9121,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7897.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7897.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7897.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7897.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7897.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8134.41,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7897.49,8134.41,
MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,9122,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8312.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8312.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8312.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8312.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8312.67,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8562.05,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8312.67,8562.05,
MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,9123,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13416.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13416.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13416.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,13416.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13416.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,13818.51,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,13416.03,13818.51,
MUSCULOSKELETAL AND OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,9124,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23409.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23409.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23409.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,23409.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,23409.93,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,24112.23,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,23409.93,24112.23,
MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE,9301,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3251.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3251.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3251.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3251.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3251.74,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3349.29,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3251.74,3349.29,
MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE,9302,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3791.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3791.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3791.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3791.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3791.3,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3905.04,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3791.3,3905.04,
MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE,9303,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6198.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6198.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6198.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,6198.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6198.65,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6384.61,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,6198.65,6384.61,
MULTIPLE SIGNIFICANT TRAUMA WITHOUT O.R. PROCEDURE,9304,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12392.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12392.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12392.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,12392.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12392.98,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12764.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,12392.98,12764.77,
EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,9501,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5860.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5860.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5860.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5860.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5860.03,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6035.83,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5860.03,6035.83,
EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,9502,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7759.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7759.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7759.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,7759.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7759.1,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,7991.87,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,7759.1,7991.87,
EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,9503,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,11861.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11861.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11861.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,11861.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,11861.69,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,12217.54,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,11861.69,12217.54,
EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,9504,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22001.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22001.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22001.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,22001.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22001.9,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,22661.95,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,22001.9,22661.95,
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,9511,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4477.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4477.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4477.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4477.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4477.88,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4612.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4477.88,4612.22,
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,9512,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5994.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5994.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5994.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,5994.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5994.83,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,6174.68,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,5994.83,6174.68,
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,9513,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9077.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9077.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9077.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,9077.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9077.26,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,9349.58,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,9077.26,9349.58,
MODERATELY EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,9514,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16512.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16512.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16512.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,16512.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,16512.84,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,17008.22,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,16512.84,17008.22,
NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,9521,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3735.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3735.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3735.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,3735.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3735.58,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,3847.65,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,3735.58,3847.65,
NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,9522,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4989.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4989.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4989.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,4989.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,4989.04,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,5138.71,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,4989.04,5138.71,
NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,9523,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8030.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8030.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8030.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,8030.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8030.49,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,8271.41,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,8030.49,8271.41,
NON-EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,9524,APR-DRG,,,,,inpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15421.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15421.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15421.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,15421.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15421.13,100,APR-DRG,,case rate,100% FL Medicaid APR-DRG,,,,,Other,Not Separately Reimbursable,15883.77,103,APR-DRG,,case rate,103% FL Medicaid APR-DRG,15421.13,15883.77,
SUPERFICIAL NEEDLE BIOPSY AND ASPIRATION,2,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,430.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,430.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,430.77,100,EAPG,,case rate,100% FL Medicaid EAPG,430.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,430.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,443.69,103,EAPG,,case rate,103% FL Medicaid EAPG,430.77,443.69,
"LEVEL I SKIN INCISION AND DRAINAGE, DEBRIDEMENT, DESTRUCTION, OTHER RELATED PX",3,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,112.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,112.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,112.01,100,EAPG,,case rate,100% FL Medicaid EAPG,112.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,112.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.37,103,EAPG,,case rate,103% FL Medicaid EAPG,112.01,115.37,
"LEVEL II SKIN INCISION AND DRAINAGE, DEBRIDEMENT, DESTRUCTION, OTHER RELATED PX",4,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,713.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,713.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,713.37,100,EAPG,,case rate,100% FL Medicaid EAPG,713.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,713.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,734.77,103,EAPG,,case rate,103% FL Medicaid EAPG,713.37,734.77,
NAIL PROCEDURES,5,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,42.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,42.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,42.63,100,EAPG,,case rate,100% FL Medicaid EAPG,42.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,42.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,43.91,103,EAPG,,case rate,103% FL Medicaid EAPG,42.63,43.91,
"LEVEL I SKIN EXCISIONS, BIOPSIES, AND REPAIRS",9,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,276.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,276.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,276.95,100,EAPG,,case rate,100% FL Medicaid EAPG,276.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,276.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,285.25,103,EAPG,,case rate,103% FL Medicaid EAPG,276.95,285.25,
"LEVEL II SKIN EXCISIONS, BIOPSIES, AND REPAIRS",10,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,796.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,796.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,796.01,100,EAPG,,case rate,100% FL Medicaid EAPG,796.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,796.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,819.89,103,EAPG,,case rate,103% FL Medicaid EAPG,796.01,819.89,
"LEVEL III SKIN EXCISIONS, BIOPSIES, AND REPAIRS",11,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1154.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1154.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1154.47,100,EAPG,,case rate,100% FL Medicaid EAPG,1154.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1154.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1189.1,103,EAPG,,case rate,103% FL Medicaid EAPG,1154.47,1189.1,
SIMPLE WOUND REPAIR AND TREATMENT,16,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,121.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,121.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,121.96,100,EAPG,,case rate,100% FL Medicaid EAPG,121.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,121.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,125.61,103,EAPG,,case rate,103% FL Medicaid EAPG,121.96,125.61,
INTERMEDIATE WOUND REPAIR AND TREATMENT,17,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,251.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,251.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,251.4,100,EAPG,,case rate,100% FL Medicaid EAPG,251.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,251.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,258.94,103,EAPG,,case rate,103% FL Medicaid EAPG,251.4,258.94,
COMPLEX WOUND REPAIR AND TREATMENT,18,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,656.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,656.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,656.23,100,EAPG,,case rate,100% FL Medicaid EAPG,656.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,656.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,675.92,103,EAPG,,case rate,103% FL Medicaid EAPG,656.23,675.92,
MOHS MICROGRAPHIC SURGERY,19,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,600.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,600.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,600.11,100,EAPG,,case rate,100% FL Medicaid EAPG,600.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,600.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,618.11,103,EAPG,,case rate,103% FL Medicaid EAPG,600.11,618.11,
"BREAST BIOPSIES, EXCISIONS, AND OTHER RELATED PROCEDURES",20,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,851.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,851.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,851.55,100,EAPG,,case rate,100% FL Medicaid EAPG,851.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,851.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,877.09,103,EAPG,,case rate,103% FL Medicaid EAPG,851.55,877.09,
LEVEL I MASTECTOMY AND RECONSTRUCTIVE BREAST PROCEDURES,21,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2115.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2115.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2115.92,100,EAPG,,case rate,100% FL Medicaid EAPG,2115.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2115.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2179.4,103,EAPG,,case rate,103% FL Medicaid EAPG,2115.92,2179.4,
LEVEL II MASTECTOMY AND RECONSTRUCTIVE BREAST PROCEDURES,22,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4786.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4786.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4786.9,100,EAPG,,case rate,100% FL Medicaid EAPG,4786.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4786.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4930.51,103,EAPG,,case rate,103% FL Medicaid EAPG,4786.9,4930.51,
LEVEL I FOREARM AND WRIST PROCEDURES,23,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1111.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1111.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1111.68,100,EAPG,,case rate,100% FL Medicaid EAPG,1111.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1111.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1145.04,103,EAPG,,case rate,103% FL Medicaid EAPG,1111.68,1145.04,
LEVEL II FOREARM AND WRIST PROCEDURES,24,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3567.03,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3567.03,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3567.03,100,EAPG,,case rate,100% FL Medicaid EAPG,3567.03,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3567.03,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3674.04,103,EAPG,,case rate,103% FL Medicaid EAPG,3567.03,3674.04,
LEVEL I SHOULDER AND UPPER ARM PROCEDURES,25,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3096.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3096.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3096.37,100,EAPG,,case rate,100% FL Medicaid EAPG,3096.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3096.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3189.26,103,EAPG,,case rate,103% FL Medicaid EAPG,3096.37,3189.26,
LEVEL I KNEE AND LOWER LEG PROCEDURES,26,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2108.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2108.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2108.04,100,EAPG,,case rate,100% FL Medicaid EAPG,2108.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2108.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2171.28,103,EAPG,,case rate,103% FL Medicaid EAPG,2108.04,2171.28,
LEVEL I HIP AND FEMUR PROCEDURES,27,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2476.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2476.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2476.68,100,EAPG,,case rate,100% FL Medicaid EAPG,2476.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2476.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2550.98,103,EAPG,,case rate,103% FL Medicaid EAPG,2476.68,2550.98,
LEVEL I SPINE PROCEDURES,28,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3216.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3216.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3216.22,100,EAPG,,case rate,100% FL Medicaid EAPG,3216.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3216.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3312.7,103,EAPG,,case rate,103% FL Medicaid EAPG,3216.22,3312.7,
LEVEL II SPINE PROCEDURES,29,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6459.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6459.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6459.7,100,EAPG,,case rate,100% FL Medicaid EAPG,6459.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6459.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6653.49,103,EAPG,,case rate,103% FL Medicaid EAPG,6459.7,6653.49,
LEVEL I HAND PROCEDURES,33,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,855.72,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,855.72,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,855.72,100,EAPG,,case rate,100% FL Medicaid EAPG,855.72,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,855.72,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,881.39,103,EAPG,,case rate,103% FL Medicaid EAPG,855.72,881.39,
LEVEL II HAND PROCEDURES,34,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1397.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1397.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1397.64,100,EAPG,,case rate,100% FL Medicaid EAPG,1397.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1397.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1439.57,103,EAPG,,case rate,103% FL Medicaid EAPG,1397.64,1439.57,
LEVEL I FOOT PROCEDURES,35,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1402.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1402.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1402.44,100,EAPG,,case rate,100% FL Medicaid EAPG,1402.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1402.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1444.51,103,EAPG,,case rate,103% FL Medicaid EAPG,1402.44,1444.51,
LEVEL II FOOT PROCEDURES,36,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3716.6,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3716.6,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3716.6,100,EAPG,,case rate,100% FL Medicaid EAPG,3716.6,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3716.6,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3828.1,103,EAPG,,case rate,103% FL Medicaid EAPG,3716.6,3828.1,
LEVEL I ARTHROSCOPY,37,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1393.51,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1393.51,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1393.51,100,EAPG,,case rate,100% FL Medicaid EAPG,1393.51,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1393.51,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1435.31,103,EAPG,,case rate,103% FL Medicaid EAPG,1393.51,1435.31,
LEVEL II ARTHROSCOPY,38,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3616.17,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3616.17,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3616.17,100,EAPG,,case rate,100% FL Medicaid EAPG,3616.17,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3616.17,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3724.66,103,EAPG,,case rate,103% FL Medicaid EAPG,3616.17,3724.66,
CAST APPLICATION OR REPLACEMENT,39,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,126.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.95,100,EAPG,,case rate,100% FL Medicaid EAPG,126.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,130.76,103,EAPG,,case rate,103% FL Medicaid EAPG,126.95,130.76,
MINOR SPLINT AND STRAPPING APPLICATION,40,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,47.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,47.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,47.62,100,EAPG,,case rate,100% FL Medicaid EAPG,47.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,47.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,49.05,103,EAPG,,case rate,103% FL Medicaid EAPG,47.62,49.05,
CLOSED TREATMENT FX AND DISLOCATION,41,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,312.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,312.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,312.28,100,EAPG,,case rate,100% FL Medicaid EAPG,312.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,312.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,321.65,103,EAPG,,case rate,103% FL Medicaid EAPG,312.28,321.65,
OPEN OR PERCUTANEOUS TREATMENT OF FRACTURES,43,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3490,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3490,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3490,100,EAPG,,case rate,100% FL Medicaid EAPG,3490,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3490,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3594.7,103,EAPG,,case rate,103% FL Medicaid EAPG,3490,3594.7,
BONE OR JOINT MANIPULATION UNDER ANESTHESIA,44,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,650.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,650.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,650.38,100,EAPG,,case rate,100% FL Medicaid EAPG,650.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,650.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,669.89,103,EAPG,,case rate,103% FL Medicaid EAPG,650.38,669.89,
LEVEL I ARTHROPLASTY,46,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2275.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2275.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2275.36,100,EAPG,,case rate,100% FL Medicaid EAPG,2275.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2275.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2343.62,103,EAPG,,case rate,103% FL Medicaid EAPG,2275.36,2343.62,
LEVEL II ARTHROPLASTY,47,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6052.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6052.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6052.96,100,EAPG,,case rate,100% FL Medicaid EAPG,6052.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6052.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6234.54,103,EAPG,,case rate,103% FL Medicaid EAPG,6052.96,6234.54,
"LEVEL I JOINT, TENDON, OR LIGAMENT INJECTION PROCEDURES",49,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,159.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,159.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,159.12,100,EAPG,,case rate,100% FL Medicaid EAPG,159.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,159.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,163.9,103,EAPG,,case rate,103% FL Medicaid EAPG,159.12,163.9,
"LEVEL II JOINT, TENDON, OR LIGAMENT INJECTION PROCEDURES",50,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,286.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,286.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,286.35,100,EAPG,,case rate,100% FL Medicaid EAPG,286.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,286.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,294.94,103,EAPG,,case rate,103% FL Medicaid EAPG,286.35,294.94,
"MUSCULOSKELETAL EXCISIONS, BIOPSIES, AND DRAINAGE PROCEDURES",51,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1171.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1171.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1171.12,100,EAPG,,case rate,100% FL Medicaid EAPG,1171.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1171.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1206.26,103,EAPG,,case rate,103% FL Medicaid EAPG,1171.12,1206.26,
LEVEL II KNEE AND LOWER LEG PROCEDURES,52,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4942.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4942.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4942.91,100,EAPG,,case rate,100% FL Medicaid EAPG,4942.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4942.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5091.2,103,EAPG,,case rate,103% FL Medicaid EAPG,4942.91,5091.2,
SPINE INJECTIONS AND OTHER RELATED PROCEDURES,53,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,489.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,489.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,489.74,100,EAPG,,case rate,100% FL Medicaid EAPG,489.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,489.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,504.43,103,EAPG,,case rate,103% FL Medicaid EAPG,489.74,504.43,
FIXATION DEVICE INSERTION OR REPLACEMENT PROCEDURES,54,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1535.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1535.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1535.86,100,EAPG,,case rate,100% FL Medicaid EAPG,1535.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1535.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1581.94,103,EAPG,,case rate,103% FL Medicaid EAPG,1535.86,1581.94,
LEVEL II HIP AND FEMUR PROCEDURES,55,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7244.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7244.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7244.4,100,EAPG,,case rate,100% FL Medicaid EAPG,7244.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7244.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7461.73,103,EAPG,,case rate,103% FL Medicaid EAPG,7244.4,7461.73,
SKIN AND CONNECTIVE TISSUE GRAFTING AND FLAP PROCEDURES,56,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1243.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1243.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1243.47,100,EAPG,,case rate,100% FL Medicaid EAPG,1243.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1243.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1280.77,103,EAPG,,case rate,103% FL Medicaid EAPG,1243.47,1280.77,
LEVEL III SPINE PROCEDURES,57,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10570.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10570.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10570.91,100,EAPG,,case rate,100% FL Medicaid EAPG,10570.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10570.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10888.04,103,EAPG,,case rate,103% FL Medicaid EAPG,10570.91,10888.04,
LEVEL II SHOULDER AND UPPER ARM PROCEDURES,58,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6094.53,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6094.53,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6094.53,100,EAPG,,case rate,100% FL Medicaid EAPG,6094.53,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6094.53,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6277.37,103,EAPG,,case rate,103% FL Medicaid EAPG,6094.53,6277.37,
ARTERIOVENOUS FISTULA CREATION OR REVISION FOR HEMODIALYSIS,59,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2308.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2308.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2308.55,100,EAPG,,case rate,100% FL Medicaid EAPG,2308.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2308.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2377.8,103,EAPG,,case rate,103% FL Medicaid EAPG,2308.55,2377.8,
PULMONARY FUNCTION TESTS,60,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,67.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,67.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,67.94,100,EAPG,,case rate,100% FL Medicaid EAPG,67.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,67.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,69.98,103,EAPG,,case rate,103% FL Medicaid EAPG,67.94,69.98,
LEVEL I ENDOSCOPY OF THE UPPER AIRWAY,62,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,375.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,375.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,375.66,100,EAPG,,case rate,100% FL Medicaid EAPG,375.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,375.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,386.93,103,EAPG,,case rate,103% FL Medicaid EAPG,375.66,386.93,
LEVEL II ENDOSCOPY OF THE UPPER AIRWAY,63,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1226.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1226.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1226.82,100,EAPG,,case rate,100% FL Medicaid EAPG,1226.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1226.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1263.62,103,EAPG,,case rate,103% FL Medicaid EAPG,1226.82,1263.62,
LEVEL I LOWER AIRWAY ENDOSCOPY,64,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1175.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1175.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1175.45,100,EAPG,,case rate,100% FL Medicaid EAPG,1175.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1175.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1210.71,103,EAPG,,case rate,103% FL Medicaid EAPG,1175.45,1210.71,
PULMONARY REHABILITATIVE SERVICES,66,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,22.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,22.04,100,EAPG,,case rate,100% FL Medicaid EAPG,22.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,22.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,22.7,103,EAPG,,case rate,103% FL Medicaid EAPG,22.04,22.7,
VENTILATION ASSISTANCE AND MANAGEMENT,67,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,765.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,765.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,765.12,100,EAPG,,case rate,100% FL Medicaid EAPG,765.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,765.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,788.08,103,EAPG,,case rate,103% FL Medicaid EAPG,765.12,788.08,
"THORACENTESIS, RELATED BIOPSY AND PLEURAL DRAINAGE PROCEDURES",68,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,648.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,648.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,648.31,100,EAPG,,case rate,100% FL Medicaid EAPG,648.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,648.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,667.76,103,EAPG,,case rate,103% FL Medicaid EAPG,648.31,667.76,
LEVEL I THORACIC AND CHEST PROCEDURES,69,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1483.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1483.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1483.79,100,EAPG,,case rate,100% FL Medicaid EAPG,1483.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1483.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1528.31,103,EAPG,,case rate,103% FL Medicaid EAPG,1483.79,1528.31,
LEVEL II THORACIC AND CHEST PROCEDURES,70,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3275.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3275.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3275.26,100,EAPG,,case rate,100% FL Medicaid EAPG,3275.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3275.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3373.52,103,EAPG,,case rate,103% FL Medicaid EAPG,3275.26,3373.52,
LEVEL II LOWER AIRWAY ENDOSCOPY,71,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2487.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2487.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2487.33,100,EAPG,,case rate,100% FL Medicaid EAPG,2487.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2487.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2561.95,103,EAPG,,case rate,103% FL Medicaid EAPG,2487.33,2561.95,
TRACHEOSTOMY AND RELATED TRACHEAL PROCEDURES,72,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1432.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1432.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1432.82,100,EAPG,,case rate,100% FL Medicaid EAPG,1432.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1432.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1475.8,103,EAPG,,case rate,103% FL Medicaid EAPG,1432.82,1475.8,
DIAPHRAGMATIC PROCEDURES AND RELATED HERNIA REPAIR,73,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4252.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4252.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4252.44,100,EAPG,,case rate,100% FL Medicaid EAPG,4252.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4252.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4380.01,103,EAPG,,case rate,103% FL Medicaid EAPG,4252.44,4380.01,
"REVISION, REPLACEMENT OR REMOVAL OF CARDIAC DEVICE COMPONENT",74,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,975.69,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,975.69,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,975.69,100,EAPG,,case rate,100% FL Medicaid EAPG,975.69,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,975.69,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1004.96,103,EAPG,,case rate,103% FL Medicaid EAPG,975.69,1004.96,
LEVEL I CENTRAL VENOUS ACCESS PROCEDURES,75,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,755.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,755.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,755.68,100,EAPG,,case rate,100% FL Medicaid EAPG,755.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,755.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,778.35,103,EAPG,,case rate,103% FL Medicaid EAPG,755.68,778.35,
"REVISION, REPAIR OR REMOVAL OF CENTRAL VENOUS ACCESS DEVICE",76,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,473.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,473.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,473.86,100,EAPG,,case rate,100% FL Medicaid EAPG,473.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,473.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,488.08,103,EAPG,,case rate,103% FL Medicaid EAPG,473.86,488.08,
LEVEL I PERIPHERAL ENDOVASCULAR AND TRANSCATHETER PROCEDURES,77,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2460.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2460.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2460.96,100,EAPG,,case rate,100% FL Medicaid EAPG,2460.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2460.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2534.79,103,EAPG,,case rate,103% FL Medicaid EAPG,2460.96,2534.79,
"LEVEL I PERIPHERAL VASCULAR REPAIR, LIGATION OR RECONSTRUCTION",78,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1365.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1365.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1365.5,100,EAPG,,case rate,100% FL Medicaid EAPG,1365.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1365.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1406.47,103,EAPG,,case rate,103% FL Medicaid EAPG,1365.5,1406.47,
LEVEL II PERIPHERAL ENDOVASCULAR AND TRANSCATHETER PROCEDURES,79,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4215.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4215.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4215.42,100,EAPG,,case rate,100% FL Medicaid EAPG,4215.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4215.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4341.89,103,EAPG,,case rate,103% FL Medicaid EAPG,4215.42,4341.89,
EXERCISE TOLERANCE TESTS,80,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,109.67,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,109.67,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,109.67,100,EAPG,,case rate,100% FL Medicaid EAPG,109.67,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,109.67,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,112.96,103,EAPG,,case rate,103% FL Medicaid EAPG,109.67,112.96,
ECHOCARDIOGRAPHY,81,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,301.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,301.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,301.28,100,EAPG,,case rate,100% FL Medicaid EAPG,301.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,301.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,310.32,103,EAPG,,case rate,103% FL Medicaid EAPG,301.28,310.32,
COMPREHENSIVE CARDIAC ELECTROPHYSIOLOGIC PROCEDURES WITH ABLATION,82,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10917.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10917.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10917.63,100,EAPG,,case rate,100% FL Medicaid EAPG,10917.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10917.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,11245.16,103,EAPG,,case rate,103% FL Medicaid EAPG,10917.63,11245.16,
LEVEL II CENTRAL VENOUS ACCESS PROCEDURES,83,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1378.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1378.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1378.88,100,EAPG,,case rate,100% FL Medicaid EAPG,1378.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1378.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1420.25,103,EAPG,,case rate,103% FL Medicaid EAPG,1378.88,1420.25,
CARDIAC CATHETERIZATION PROCEDURES,84,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1588.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1588.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1588.63,100,EAPG,,case rate,100% FL Medicaid EAPG,1588.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1588.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1636.29,103,EAPG,,case rate,103% FL Medicaid EAPG,1588.63,1636.29,
LEVEL III PERIPHERAL ENDOVASCULAR AND TRANSCATHETER PROCEDURES,85,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7047.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7047.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7047.29,100,EAPG,,case rate,100% FL Medicaid EAPG,7047.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7047.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7258.7,103,EAPG,,case rate,103% FL Medicaid EAPG,7047.29,7258.7,
PACEMAKER AND OTHER CARDIOVASCULAR DEVICE INSERTION AND REPLACEMENT,86,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5079.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5079.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5079.14,100,EAPG,,case rate,100% FL Medicaid EAPG,5079.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5079.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5231.51,103,EAPG,,case rate,103% FL Medicaid EAPG,5079.14,5231.51,
REMOVAL OR REVISION OF PACEMAKERS AND OTHER CARDIOVASCULAR DEVICES,87,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4626.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4626.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4626.77,100,EAPG,,case rate,100% FL Medicaid EAPG,4626.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4626.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4765.57,103,EAPG,,case rate,103% FL Medicaid EAPG,4626.77,4765.57,
LEVEL I VARICOSE VEIN AND RELATED PROCEDURES,90,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,398.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,398.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,398.12,100,EAPG,,case rate,100% FL Medicaid EAPG,398.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,398.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,410.07,103,EAPG,,case rate,103% FL Medicaid EAPG,398.12,410.07,
"LEVEL II PERIPHERAL VASCULAR REPAIR, LIGATION OR RECONSTRUCTION",91,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2602.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2602.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2602.61,100,EAPG,,case rate,100% FL Medicaid EAPG,2602.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2602.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2680.69,103,EAPG,,case rate,103% FL Medicaid EAPG,2602.61,2680.69,
RESUSCITATION,92,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,476.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,476.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,476.12,100,EAPG,,case rate,100% FL Medicaid EAPG,476.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,476.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,490.41,103,EAPG,,case rate,103% FL Medicaid EAPG,476.12,490.41,
CARDIOVERSION,93,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,416.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,416.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,416.84,100,EAPG,,case rate,100% FL Medicaid EAPG,416.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,416.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,429.35,103,EAPG,,case rate,103% FL Medicaid EAPG,416.84,429.35,
CARDIAC REHABILITATION,94,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,96.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,96.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,96.29,100,EAPG,,case rate,100% FL Medicaid EAPG,96.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,96.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.18,103,EAPG,,case rate,103% FL Medicaid EAPG,96.29,99.18,
CARDIAC ELECTROPHYSIOLOGIC PROCEDURES INCLUDING PACING AND RECORDING,96,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4375.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4375.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4375.91,100,EAPG,,case rate,100% FL Medicaid EAPG,4375.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4375.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4507.19,103,EAPG,,case rate,103% FL Medicaid EAPG,4375.91,4507.19,
AICD AND RELATED CARDIAC DEVICE INSERTION OR REPLACEMENT,97,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14379.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,14379.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,14379.86,100,EAPG,,case rate,100% FL Medicaid EAPG,14379.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,14379.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,14811.26,103,EAPG,,case rate,103% FL Medicaid EAPG,14379.86,14811.26,
LEVEL I PERCUTANEOUS CORONARY AND INTRACARDIAC INTERVENTIONAL PROCEDURES,99,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5484.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5484.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5484.2,100,EAPG,,case rate,100% FL Medicaid EAPG,5484.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5484.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5648.73,103,EAPG,,case rate,103% FL Medicaid EAPG,5484.2,5648.73,
LEVEL II VARICOSE VEIN AND RELATED PROCEDURES,103,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1697.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1697.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1697.09,100,EAPG,,case rate,100% FL Medicaid EAPG,1697.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1697.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1748,103,EAPG,,case rate,103% FL Medicaid EAPG,1697.09,1748,
MAJOR OPEN CORONARY ARTERY PROCEDURES INCLUDING CABG,104,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10327.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10327.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10327.85,100,EAPG,,case rate,100% FL Medicaid EAPG,10327.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10327.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10637.69,103,EAPG,,case rate,103% FL Medicaid EAPG,10327.85,10637.69,
MAJOR OPEN CARDIAC AND CARDIAC VALVE PROCEDURES,105,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7198.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7198.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7198.96,100,EAPG,,case rate,100% FL Medicaid EAPG,7198.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7198.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7414.93,103,EAPG,,case rate,103% FL Medicaid EAPG,7198.96,7414.93,
MAJOR OPEN ABDOMINAL AND THORACIC VASCULAR PROCEDURES,106,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5486.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5486.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5486.78,100,EAPG,,case rate,100% FL Medicaid EAPG,5486.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5486.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5651.38,103,EAPG,,case rate,103% FL Medicaid EAPG,5486.78,5651.38,
CHOLECYSTECTOMY AND RELATED BILIARY PROCEDURES,107,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2333.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2333.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2333.94,100,EAPG,,case rate,100% FL Medicaid EAPG,2333.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2333.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2403.95,103,EAPG,,case rate,103% FL Medicaid EAPG,2333.94,2403.95,
OTHER INTRA-ABDOMINAL AND INTRAPERITONEAL SURGICAL PROCEDURES,108,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2419.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2419.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2419.19,100,EAPG,,case rate,100% FL Medicaid EAPG,2419.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2419.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2491.77,103,EAPG,,case rate,103% FL Medicaid EAPG,2419.19,2491.77,
ANCILLARY DRUG ADMINISTRATION,109,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,33.15,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,33.15,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,33.15,100,EAPG,,case rate,100% FL Medicaid EAPG,33.15,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,33.15,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,34.15,103,EAPG,,case rate,103% FL Medicaid EAPG,33.15,34.15,
PHARMACOTHERAPY BY EXTENDED INFUSION,110,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,329.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,329.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,329.13,100,EAPG,,case rate,100% FL Medicaid EAPG,329.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,329.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,339,103,EAPG,,case rate,103% FL Medicaid EAPG,329.13,339,
PHARMACOTHERAPY EXCEPT BY EXTENDED INFUSION,111,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,182.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,182.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,182.02,100,EAPG,,case rate,100% FL Medicaid EAPG,182.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,182.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,187.48,103,EAPG,,case rate,103% FL Medicaid EAPG,182.02,187.48,
LEVEL I BLOOD PRODUCT EXCHANGE SERVICES,113,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,278.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,278.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,278.86,100,EAPG,,case rate,100% FL Medicaid EAPG,278.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,278.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,287.22,103,EAPG,,case rate,103% FL Medicaid EAPG,278.86,287.22,
LEVEL II BLOOD PRODUCT EXCHANGE SERVICES,114,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1034.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1034.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1034.31,100,EAPG,,case rate,100% FL Medicaid EAPG,1034.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1034.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1065.34,103,EAPG,,case rate,103% FL Medicaid EAPG,1034.31,1065.34,
DEEP LYMPH STRUCTURE PROCEDURES,115,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2129.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2129.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2129.3,100,EAPG,,case rate,100% FL Medicaid EAPG,2129.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2129.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2193.18,103,EAPG,,case rate,103% FL Medicaid EAPG,2129.3,2193.18,
LEVEL I ALLERGY TESTS,116,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20.51,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,20.51,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,20.51,100,EAPG,,case rate,100% FL Medicaid EAPG,20.51,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,20.51,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,21.13,103,EAPG,,case rate,103% FL Medicaid EAPG,20.51,21.13,
NUTRITION THERAPY,118,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,132.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,132.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,132.45,100,EAPG,,case rate,100% FL Medicaid EAPG,132.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,132.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,136.42,103,EAPG,,case rate,103% FL Medicaid EAPG,132.45,136.42,
CAR T-CELL IMMUNOTHERAPY PREPARATION SERVICES,119,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,472.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,472.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,472.89,100,EAPG,,case rate,100% FL Medicaid EAPG,472.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,472.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,487.07,103,EAPG,,case rate,103% FL Medicaid EAPG,472.89,487.07,
CAR T-CELL IMMUNOTHERAPY,120,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24610.06,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,24610.06,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,24610.06,100,EAPG,,case rate,100% FL Medicaid EAPG,24610.06,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,24610.06,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,25348.36,103,EAPG,,case rate,103% FL Medicaid EAPG,24610.06,25348.36,
LEVEL II PERCUTANEOUS CORONARY AND INTRACARDIAC INTERVENTIONAL PROCEDURES,121,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9361.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,9361.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,9361.25,100,EAPG,,case rate,100% FL Medicaid EAPG,9361.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,9361.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,9642.09,103,EAPG,,case rate,103% FL Medicaid EAPG,9361.25,9642.09,
PERCUTANEOUS INTRA-ABDOMINAL OR INTRATHORACIC VASCULAR PROCEDURES,122,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,9941.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,9941.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,9941.04,100,EAPG,,case rate,100% FL Medicaid EAPG,9941.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,9941.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10239.27,103,EAPG,,case rate,103% FL Medicaid EAPG,9941.04,10239.27,
PERIPHERAL VASCULAR BYPASS PROCEDURES,123,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3156.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3156.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3156.62,100,EAPG,,case rate,100% FL Medicaid EAPG,3156.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3156.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3251.32,103,EAPG,,case rate,103% FL Medicaid EAPG,3156.62,3251.32,
BONE MARROW BIOPSIES,124,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1206.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1206.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1206.07,100,EAPG,,case rate,100% FL Medicaid EAPG,1206.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1206.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1242.25,103,EAPG,,case rate,103% FL Medicaid EAPG,1206.07,1242.25,
LEVEL I ESOPHAGEAL AND GASTRIC SURGICAL PROCEDURES,125,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2170.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2170.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2170.91,100,EAPG,,case rate,100% FL Medicaid EAPG,2170.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2170.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2236.04,103,EAPG,,case rate,103% FL Medicaid EAPG,2170.91,2236.04,
LEVEL II ESOPHAGEAL AND GASTRIC SURGICAL PROCEDURES,126,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2387.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2387.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2387.1,100,EAPG,,case rate,100% FL Medicaid EAPG,2387.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2387.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2458.71,103,EAPG,,case rate,103% FL Medicaid EAPG,2387.1,2458.71,
LEVEL I SMALL AND LARGE INTESTINE SURGICAL PROCEDURES,127,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1319.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1319.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1319.79,100,EAPG,,case rate,100% FL Medicaid EAPG,1319.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1319.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1359.39,103,EAPG,,case rate,103% FL Medicaid EAPG,1319.79,1359.39,
LEVEL II SMALL AND LARGE INTESTINE SURGICAL PROCEDURES,128,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2599.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2599.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2599.73,100,EAPG,,case rate,100% FL Medicaid EAPG,2599.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2599.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2677.72,103,EAPG,,case rate,103% FL Medicaid EAPG,2599.73,2677.72,
ESOPHAGOGASTRIC RESTRICTIVE PROCEDURES AND GASTRIC FUNDOPLICATION,129,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3353.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3353.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3353.5,100,EAPG,,case rate,100% FL Medicaid EAPG,3353.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3353.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3454.11,103,EAPG,,case rate,103% FL Medicaid EAPG,3353.5,3454.11,
MINOR GASTROINTESTINAL PROCEDURES INCLUDING TUBE INSERTION OR PLACEMENT,130,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,230.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,230.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,230.3,100,EAPG,,case rate,100% FL Medicaid EAPG,230.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,230.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,237.21,103,EAPG,,case rate,103% FL Medicaid EAPG,230.3,237.21,
LEVEL I UPPER GI ENDOSCOPY,134,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,644.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,644.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,644.88,100,EAPG,,case rate,100% FL Medicaid EAPG,644.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,644.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,664.23,103,EAPG,,case rate,103% FL Medicaid EAPG,644.88,664.23,
LEVEL II UPPER GI ENDOSCOPY,135,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1361.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1361.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1361.02,100,EAPG,,case rate,100% FL Medicaid EAPG,1361.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1361.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1401.85,103,EAPG,,case rate,103% FL Medicaid EAPG,1361.02,1401.85,
LEVEL I LOWER GI ENDOSCOPY,136,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,640.83,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,640.83,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,640.83,100,EAPG,,case rate,100% FL Medicaid EAPG,640.83,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,640.83,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,660.05,103,EAPG,,case rate,103% FL Medicaid EAPG,640.83,660.05,
LEVEL II LOWER GI ENDOSCOPY,137,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1354.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1354.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1354.54,100,EAPG,,case rate,100% FL Medicaid EAPG,1354.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1354.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1395.18,103,EAPG,,case rate,103% FL Medicaid EAPG,1354.54,1395.18,
LEVEL I ERCP AND RELATED ENDOSCOPIC PROCEDURES,138,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1728.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1728.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1728.64,100,EAPG,,case rate,100% FL Medicaid EAPG,1728.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1728.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1780.5,103,EAPG,,case rate,103% FL Medicaid EAPG,1728.64,1780.5,
LEVEL I ANAL AND RECTAL PROCEDURES,141,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,944.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,944.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,944.33,100,EAPG,,case rate,100% FL Medicaid EAPG,944.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,944.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,972.66,103,EAPG,,case rate,103% FL Medicaid EAPG,944.33,972.66,
LEVEL II ANAL AND RECTAL PROCEDURES,142,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1476.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1476.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1476.46,100,EAPG,,case rate,100% FL Medicaid EAPG,1476.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1476.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1520.75,103,EAPG,,case rate,103% FL Medicaid EAPG,1476.46,1520.75,
ABDOMINAL PARACENTESIS AND RELATED PERITONEAL DRAINAGE PROCEDURES,150,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,472.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,472.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,472.58,100,EAPG,,case rate,100% FL Medicaid EAPG,472.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,472.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,486.75,103,EAPG,,case rate,103% FL Medicaid EAPG,472.58,486.75,
LEVEL I HEPATOBILIARY AND PANCREAS PROCEDURES,151,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1474.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1474.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1474.08,100,EAPG,,case rate,100% FL Medicaid EAPG,1474.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1474.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1518.3,103,EAPG,,case rate,103% FL Medicaid EAPG,1474.08,1518.3,
LEVEL II HEPATOBILIARY AND PANCREAS PROCEDURES,152,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3653.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3653.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3653.3,100,EAPG,,case rate,100% FL Medicaid EAPG,3653.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3653.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3762.9,103,EAPG,,case rate,103% FL Medicaid EAPG,3653.3,3762.9,
LEVEL II ERCP AND RELATED ENDOSCOPIC PROCEDURES,153,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2890.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2890.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2890.56,100,EAPG,,case rate,100% FL Medicaid EAPG,2890.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2890.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2977.28,103,EAPG,,case rate,103% FL Medicaid EAPG,2890.56,2977.28,
LEVEL III UPPER GI ENDOSCOPY,154,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2633.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2633.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2633.58,100,EAPG,,case rate,100% FL Medicaid EAPG,2633.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2633.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2712.59,103,EAPG,,case rate,103% FL Medicaid EAPG,2633.58,2712.59,
LEVEL III BLOOD PRODUCT EXCHANGE SERVICES,155,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2682.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2682.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2682.1,100,EAPG,,case rate,100% FL Medicaid EAPG,2682.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2682.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2762.56,103,EAPG,,case rate,103% FL Medicaid EAPG,2682.1,2762.56,
OCULAR IMAGING AND RELATED SERVICES,156,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,37.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,37.36,100,EAPG,,case rate,100% FL Medicaid EAPG,37.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,37.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,38.48,103,EAPG,,case rate,103% FL Medicaid EAPG,37.36,38.48,
REPRODUCTIVE PATHOLOGY TESTS,157,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,68.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,68.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,68.41,100,EAPG,,case rate,100% FL Medicaid EAPG,68.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,68.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,70.46,103,EAPG,,case rate,103% FL Medicaid EAPG,68.41,70.46,
PATHOLOGY CONSULTATION AND INTERPRETATION,158,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,61.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,61.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,61.47,100,EAPG,,case rate,100% FL Medicaid EAPG,61.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,61.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,63.31,103,EAPG,,case rate,103% FL Medicaid EAPG,61.47,63.31,
MINOR UROLOGY SERVICES,159,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,53.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,53.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,53.82,100,EAPG,,case rate,100% FL Medicaid EAPG,53.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,53.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,55.44,103,EAPG,,case rate,103% FL Medicaid EAPG,53.82,55.44,
URINARY STUDIES AND PROCEDURES,161,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,256.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,256.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,256.78,100,EAPG,,case rate,100% FL Medicaid EAPG,256.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,256.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,264.49,103,EAPG,,case rate,103% FL Medicaid EAPG,256.78,264.49,
LEVEL I URETHRAL PROCEDURES,166,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1934.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1934.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1934.33,100,EAPG,,case rate,100% FL Medicaid EAPG,1934.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1934.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1992.36,103,EAPG,,case rate,103% FL Medicaid EAPG,1934.33,1992.36,
LEVEL II URETHRAL PROCEDURES,167,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3814.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3814.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3814.1,100,EAPG,,case rate,100% FL Medicaid EAPG,3814.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3814.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3928.53,103,EAPG,,case rate,103% FL Medicaid EAPG,3814.1,3928.53,
DIALYSIS PROCEDURES,168,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,569.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,569.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,569.34,100,EAPG,,case rate,100% FL Medicaid EAPG,569.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,569.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,586.42,103,EAPG,,case rate,103% FL Medicaid EAPG,569.34,586.42,
LEVEL I KIDNEY AND URETERAL PROCEDURES,170,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,956.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,956.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,956.23,100,EAPG,,case rate,100% FL Medicaid EAPG,956.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,956.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,984.91,103,EAPG,,case rate,103% FL Medicaid EAPG,956.23,984.91,
LEVEL II KIDNEY AND URETERAL PROCEDURES,171,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1879.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1879.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1879.46,100,EAPG,,case rate,100% FL Medicaid EAPG,1879.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1879.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1935.84,103,EAPG,,case rate,103% FL Medicaid EAPG,1879.46,1935.84,
LEVEL III KIDNEY AND URETERAL PROCEDURES,172,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4476.69,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4476.69,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4476.69,100,EAPG,,case rate,100% FL Medicaid EAPG,4476.69,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4476.69,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4610.99,103,EAPG,,case rate,103% FL Medicaid EAPG,4476.69,4610.99,
LEVEL I BLADDER AND URETERAL PROCEDURES,173,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1009.03,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1009.03,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1009.03,100,EAPG,,case rate,100% FL Medicaid EAPG,1009.03,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1009.03,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1039.3,103,EAPG,,case rate,103% FL Medicaid EAPG,1009.03,1039.3,
LEVEL II BLADDER AND URETERAL PROCEDURES,174,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2689.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2689.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2689.74,100,EAPG,,case rate,100% FL Medicaid EAPG,2689.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2689.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2770.44,103,EAPG,,case rate,103% FL Medicaid EAPG,2689.74,2770.44,
LEVEL III BLADDER AND URETERAL PROCEDURES,175,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3215.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3215.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3215.94,100,EAPG,,case rate,100% FL Medicaid EAPG,3215.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3215.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3312.42,103,EAPG,,case rate,103% FL Medicaid EAPG,3215.94,3312.42,
LEVEL I PROSTATE PROCEDURES,176,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1101.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1101.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1101.31,100,EAPG,,case rate,100% FL Medicaid EAPG,1101.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1101.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1134.35,103,EAPG,,case rate,103% FL Medicaid EAPG,1101.31,1134.35,
MINOR DERMATOLOGY SERVICES,177,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,22.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,22.23,100,EAPG,,case rate,100% FL Medicaid EAPG,22.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,22.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,22.9,103,EAPG,,case rate,103% FL Medicaid EAPG,22.23,22.9,
ANTEPARTUM PROCEDURES,178,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,379.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,379.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,379.52,100,EAPG,,case rate,100% FL Medicaid EAPG,379.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,379.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,390.9,103,EAPG,,case rate,103% FL Medicaid EAPG,379.52,390.9,
ECTOPIC PREGNANCY PROCEDURES,179,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2288.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2288.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2288.27,100,EAPG,,case rate,100% FL Medicaid EAPG,2288.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2288.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2356.91,103,EAPG,,case rate,103% FL Medicaid EAPG,2288.27,2356.91,
TESTICULAR AND EPIDIDYMAL PROCEDURES,180,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1846.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1846.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1846.89,100,EAPG,,case rate,100% FL Medicaid EAPG,1846.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1846.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1902.3,103,EAPG,,case rate,103% FL Medicaid EAPG,1846.89,1902.3,
INSERTION OF PENILE PROSTHESIS,182,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8722.65,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,8722.65,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,8722.65,100,EAPG,,case rate,100% FL Medicaid EAPG,8722.65,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,8722.65,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,8984.33,103,EAPG,,case rate,103% FL Medicaid EAPG,8722.65,8984.33,
LEVEL I PENILE PROCEDURES,183,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1267.06,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1267.06,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1267.06,100,EAPG,,case rate,100% FL Medicaid EAPG,1267.06,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1267.06,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1305.08,103,EAPG,,case rate,103% FL Medicaid EAPG,1267.06,1305.08,
LEVEL II PROSTATE PROCEDURES,184,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2903.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2903.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2903.31,100,EAPG,,case rate,100% FL Medicaid EAPG,2903.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2903.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2990.41,103,EAPG,,case rate,103% FL Medicaid EAPG,2903.31,2990.41,
LEVEL II PENILE PROCEDURES,187,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2163.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2163.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2163.66,100,EAPG,,case rate,100% FL Medicaid EAPG,2163.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2163.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2228.57,103,EAPG,,case rate,103% FL Medicaid EAPG,2163.66,2228.57,
LEVEL I PERINEAL AND VAGINAL GYNECOLOGICAL PROCEDURES,188,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1635,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1635,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1635,100,EAPG,,case rate,100% FL Medicaid EAPG,1635,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1635,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1684.05,103,EAPG,,case rate,103% FL Medicaid EAPG,1635,1684.05,
LEVEL II PERINEAL AND VAGINAL GYNECOLOGICAL PROCEDURES,189,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3686.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3686.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3686.14,100,EAPG,,case rate,100% FL Medicaid EAPG,3686.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3686.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3796.72,103,EAPG,,case rate,103% FL Medicaid EAPG,3686.14,3796.72,
ARTIFICIAL FERTILIZATION,190,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,345.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,345.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,345.31,100,EAPG,,case rate,100% FL Medicaid EAPG,345.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,345.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,355.67,103,EAPG,,case rate,103% FL Medicaid EAPG,345.31,355.67,
LEVEL I FETAL PROCEDURES,191,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,126.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.79,100,EAPG,,case rate,100% FL Medicaid EAPG,126.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,130.6,103,EAPG,,case rate,103% FL Medicaid EAPG,126.79,130.6,
LEVEL II FETAL PROCEDURES,192,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,655.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,655.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,655.8,100,EAPG,,case rate,100% FL Medicaid EAPG,655.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,655.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,675.48,103,EAPG,,case rate,103% FL Medicaid EAPG,655.8,675.48,
ABORTION AND MISCARRIAGE TREATMENT AND PROCEDURES,194,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1152.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1152.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1152.56,100,EAPG,,case rate,100% FL Medicaid EAPG,1152.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1152.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1187.13,103,EAPG,,case rate,103% FL Medicaid EAPG,1152.56,1187.13,
VAGINAL DELIVERY PROCEDURES,195,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1538.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1538.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1538.71,100,EAPG,,case rate,100% FL Medicaid EAPG,1538.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1538.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1584.87,103,EAPG,,case rate,103% FL Medicaid EAPG,1538.71,1584.87,
CESAREAN DELIVERY PROCEDURES,202,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1701.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1701.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1701.61,100,EAPG,,case rate,100% FL Medicaid EAPG,1701.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1701.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1752.66,103,EAPG,,case rate,103% FL Medicaid EAPG,1701.61,1752.66,
GLOBAL ANTEPARTUM AND POSTPARTUM VISITS,203,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,141.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,141.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,141.42,100,EAPG,,case rate,100% FL Medicaid EAPG,141.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,141.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,145.66,103,EAPG,,case rate,103% FL Medicaid EAPG,141.42,145.66,
LEVEL I HYSTERECTOMY AND MYOMECTOMY PROCEDURES,204,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2670.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2670.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2670.24,100,EAPG,,case rate,100% FL Medicaid EAPG,2670.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2670.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2750.35,103,EAPG,,case rate,103% FL Medicaid EAPG,2670.24,2750.35,
OBSTETRICAL PROCEDURES,205,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1141.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1141.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1141.52,100,EAPG,,case rate,100% FL Medicaid EAPG,1141.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1141.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1175.77,103,EAPG,,case rate,103% FL Medicaid EAPG,1141.52,1175.77,
LEVEL II HYSTERECTOMY AND MYOMECTOMY PROCEDURES,206,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3756.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3756.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3756.73,100,EAPG,,case rate,100% FL Medicaid EAPG,3756.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3756.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3869.43,103,EAPG,,case rate,103% FL Medicaid EAPG,3756.73,3869.43,
LEVEL I OTHER UTERINE AND ADNEXA GYNECOLOGICAL PROCEDURES,207,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1521.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1521.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1521.98,100,EAPG,,case rate,100% FL Medicaid EAPG,1521.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1521.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1567.63,103,EAPG,,case rate,103% FL Medicaid EAPG,1521.98,1567.63,
LEVEL II OTHER UTERINE AND ADNEXA GYNECOLOGICAL PROCEDURES,208,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2802.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2802.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2802.92,100,EAPG,,case rate,100% FL Medicaid EAPG,2802.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2802.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2887.01,103,EAPG,,case rate,103% FL Medicaid EAPG,2802.92,2887.01,
OTHER GYNECOLOGICAL PROCEDURES,209,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,335.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,335.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,335.68,100,EAPG,,case rate,100% FL Medicaid EAPG,335.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,335.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,345.75,103,EAPG,,case rate,103% FL Medicaid EAPG,335.68,345.75,
EXTENDED EEG STUDIES,210,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,308.03,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,308.03,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,308.03,100,EAPG,,case rate,100% FL Medicaid EAPG,308.03,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,308.03,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,317.27,103,EAPG,,case rate,103% FL Medicaid EAPG,308.03,317.27,
ELECTROENCEPHALOGRAM,211,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,239.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,239.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,239.04,100,EAPG,,case rate,100% FL Medicaid EAPG,239.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,239.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,246.21,103,EAPG,,case rate,103% FL Medicaid EAPG,239.04,246.21,
ELECTROCONVULSIVE THERAPY,212,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,308.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,308.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,308.93,100,EAPG,,case rate,100% FL Medicaid EAPG,308.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,308.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,318.19,103,EAPG,,case rate,103% FL Medicaid EAPG,308.93,318.19,
NERVE AND MUSCLE TESTS,213,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,86.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.08,100,EAPG,,case rate,100% FL Medicaid EAPG,86.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.66,103,EAPG,,case rate,103% FL Medicaid EAPG,86.08,88.66,
LEVEL I NERVOUS SYSTEM INJECTIONS INCLUDING CRANIAL TAP,214,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,257.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,257.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,257.33,100,EAPG,,case rate,100% FL Medicaid EAPG,257.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,257.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,265.05,103,EAPG,,case rate,103% FL Medicaid EAPG,257.33,265.05,
LEVEL I PERIPHERAL NERVE PROCEDURES,217,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,873.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,873.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,873.86,100,EAPG,,case rate,100% FL Medicaid EAPG,873.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,873.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,900.07,103,EAPG,,case rate,103% FL Medicaid EAPG,873.86,900.07,
LEVEL II PERIPHERAL NERVE PROCEDURES,218,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3158.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3158.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3158.61,100,EAPG,,case rate,100% FL Medicaid EAPG,3158.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3158.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3253.37,103,EAPG,,case rate,103% FL Medicaid EAPG,3158.61,3253.37,
LEVEL II NERVOUS SYSTEM INJECTIONS INCLUDING CRANIAL TAP,220,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,941.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,941.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,941.91,100,EAPG,,case rate,100% FL Medicaid EAPG,941.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,941.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,970.17,103,EAPG,,case rate,103% FL Medicaid EAPG,941.91,970.17,
SLEEP STUDIES ATTENDED,222,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,492.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,492.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,492.31,100,EAPG,,case rate,100% FL Medicaid EAPG,492.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,492.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,507.08,103,EAPG,,case rate,103% FL Medicaid EAPG,492.31,507.08,
LEVEL I NEUROSTIMULATOR AND RELATED DEVICE IMPLANTATION,223,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4001.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4001.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4001.39,100,EAPG,,case rate,100% FL Medicaid EAPG,4001.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4001.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4121.43,103,EAPG,,case rate,103% FL Medicaid EAPG,4001.39,4121.43,
LEVEL II NEUROSTIMULATOR AND RELATED DEVICE IMPLANTATION,224,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,12436.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,12436.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,12436.05,100,EAPG,,case rate,100% FL Medicaid EAPG,12436.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,12436.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,12809.14,103,EAPG,,case rate,103% FL Medicaid EAPG,12436.05,12809.14,
OTHER INTRACRANIAL NEUROSURGERY PROCEDURES,225,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2360.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2360.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2360.77,100,EAPG,,case rate,100% FL Medicaid EAPG,2360.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2360.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2431.59,103,EAPG,,case rate,103% FL Medicaid EAPG,2360.77,2431.59,
SLEEP STUDIES UNATTENDED,226,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,98.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.36,100,EAPG,,case rate,100% FL Medicaid EAPG,98.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.31,103,EAPG,,case rate,103% FL Medicaid EAPG,98.36,101.31,
LEVEL I CRANIOFACIAL BONE PROCEDURES,227,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1700.99,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1700.99,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1700.99,100,EAPG,,case rate,100% FL Medicaid EAPG,1700.99,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1700.99,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1752.02,103,EAPG,,case rate,103% FL Medicaid EAPG,1700.99,1752.02,
LEVEL II CRANIOFACIAL BONE PROCEDURES,228,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3212.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3212.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3212.55,100,EAPG,,case rate,100% FL Medicaid EAPG,3212.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3212.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3308.93,103,EAPG,,case rate,103% FL Medicaid EAPG,3212.55,3308.93,
MINOR AUDIOMETRY TESTS AND AUDIOLOGY SCREENING SERVICES,229,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,21.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,21.02,100,EAPG,,case rate,100% FL Medicaid EAPG,21.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,21.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,21.65,103,EAPG,,case rate,103% FL Medicaid EAPG,21.02,21.65,
MINOR OPHTHALMOLOGICAL PROCEDURES AND DIAGNOSTIC SERVICES,230,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,188.53,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,188.53,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,188.53,100,EAPG,,case rate,100% FL Medicaid EAPG,188.53,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,188.53,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,194.19,103,EAPG,,case rate,103% FL Medicaid EAPG,188.53,194.19,
CATARACT AND OTHER INTRAOCULAR LENS PROCEDURES,233,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1109.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1109.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1109.23,100,EAPG,,case rate,100% FL Medicaid EAPG,1109.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1109.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1142.5,103,EAPG,,case rate,103% FL Medicaid EAPG,1109.23,1142.5,
LEVEL I ANTERIOR CHAMBER EYE PROCEDURES,234,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,677.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,677.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,677.56,100,EAPG,,case rate,100% FL Medicaid EAPG,677.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,677.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,697.89,103,EAPG,,case rate,103% FL Medicaid EAPG,677.56,697.89,
LEVEL II ANTERIOR CHAMBER EYE PROCEDURES,235,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2182.03,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2182.03,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2182.03,100,EAPG,,case rate,100% FL Medicaid EAPG,2182.03,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2182.03,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2247.49,103,EAPG,,case rate,103% FL Medicaid EAPG,2182.03,2247.49,
"LEVEL I INTRAVITREAL, RETINAL AND OTHER POSTERIOR CHAMBER EYE PROCEDURES",237,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,658.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,658.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,658.61,100,EAPG,,case rate,100% FL Medicaid EAPG,658.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,658.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,678.37,103,EAPG,,case rate,103% FL Medicaid EAPG,658.61,678.37,
"LEVEL II INTRAVITREAL, RETINAL AND OTHER POSTERIOR CHAMBER EYE PROCEDURES",238,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2075.17,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2075.17,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2075.17,100,EAPG,,case rate,100% FL Medicaid EAPG,2075.17,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2075.17,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2137.42,103,EAPG,,case rate,103% FL Medicaid EAPG,2075.17,2137.42,
EXTRAOCULAR MUSCLE PROCEDURES,239,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1406.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1406.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1406.57,100,EAPG,,case rate,100% FL Medicaid EAPG,1406.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1406.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1448.77,103,EAPG,,case rate,103% FL Medicaid EAPG,1406.57,1448.77,
OCULAR RECONSTRUCTIVE PROCEDURES W OR W/O OCULAR DEVICE,241,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1950.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1950.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1950.25,100,EAPG,,case rate,100% FL Medicaid EAPG,1950.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1950.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2008.75,103,EAPG,,case rate,103% FL Medicaid EAPG,1950.25,2008.75,
CLASS II THERAPEUTIC RADIOPHARMACEUTICALS,244,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,262.75,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,262.75,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,262.75,100,EAPG,,case rate,100% FL Medicaid EAPG,262.75,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,262.75,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,270.63,103,EAPG,,case rate,103% FL Medicaid EAPG,262.75,270.63,
CLASS III THERAPEUTIC RADIOPHARMACEUTICALS,245,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8769.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,8769.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,8769.3,100,EAPG,,case rate,100% FL Medicaid EAPG,8769.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,8769.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,9032.38,103,EAPG,,case rate,103% FL Medicaid EAPG,8769.3,9032.38,
CLASS IV THERAPEUTIC RADIOPHARMACEUTICALS,246,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23186.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,23186.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,23186.52,100,EAPG,,case rate,100% FL Medicaid EAPG,23186.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,23186.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,23882.12,103,EAPG,,case rate,103% FL Medicaid EAPG,23186.52,23882.12,
LEVEL I CORNEAL AND OTHER ANTERIOR SURFACE EYE PROCEDURES,247,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,369.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,369.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,369.26,100,EAPG,,case rate,100% FL Medicaid EAPG,369.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,369.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,380.34,103,EAPG,,case rate,103% FL Medicaid EAPG,369.26,380.34,
LEVEL II CORNEAL AND OTHER ANTERIOR SURFACE EYE PROCEDURES,248,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2102,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2102,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2102,100,EAPG,,case rate,100% FL Medicaid EAPG,2102,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2102,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2165.06,103,EAPG,,case rate,103% FL Medicaid EAPG,2102,2165.06,
"MINOR EAR, NOSE, MOUTH AND THROAT PROCEDURES",249,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,118.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,118.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,118.91,100,EAPG,,case rate,100% FL Medicaid EAPG,118.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,118.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,122.48,103,EAPG,,case rate,103% FL Medicaid EAPG,118.91,122.48,
COCHLEAR DEVICE IMPLANTATION,250,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15622.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,15622.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,15622.05,100,EAPG,,case rate,100% FL Medicaid EAPG,15622.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,15622.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,16090.71,103,EAPG,,case rate,103% FL Medicaid EAPG,15622.05,16090.71,
OTORHINOLARYNGOLOGIC FUNCTION TESTS,251,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,88.06,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.06,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.06,100,EAPG,,case rate,100% FL Medicaid EAPG,88.06,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.06,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,90.71,103,EAPG,,case rate,103% FL Medicaid EAPG,88.06,90.71,
"LEVEL I EAR, NOSE, MOUTH AND THROAT PROCEDURES",252,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,912.97,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,912.97,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,912.97,100,EAPG,,case rate,100% FL Medicaid EAPG,912.97,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,912.97,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,940.36,103,EAPG,,case rate,103% FL Medicaid EAPG,912.97,940.36,
"LEVEL II EAR, NOSE, MOUTH AND THROAT PROCEDURES",253,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1737.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1737.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1737.42,100,EAPG,,case rate,100% FL Medicaid EAPG,1737.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1737.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1789.54,103,EAPG,,case rate,103% FL Medicaid EAPG,1737.42,1789.54,
"LEVEL III EAR, NOSE, MOUTH AND THROAT PROCEDURES",254,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2226.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2226.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2226.45,100,EAPG,,case rate,100% FL Medicaid EAPG,2226.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2226.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2293.24,103,EAPG,,case rate,103% FL Medicaid EAPG,2226.45,2293.24,
"LEVEL IV EAR, NOSE, MOUTH AND THROAT PROCEDURES",255,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2862.32,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2862.32,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2862.32,100,EAPG,,case rate,100% FL Medicaid EAPG,2862.32,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2862.32,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2948.19,103,EAPG,,case rate,103% FL Medicaid EAPG,2862.32,2948.19,
TONSIL AND ADENOID PROCEDURES,256,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1385.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1385.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1385.63,100,EAPG,,case rate,100% FL Medicaid EAPG,1385.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1385.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1427.2,103,EAPG,,case rate,103% FL Medicaid EAPG,1385.63,1427.2,
AUDIOMETRY,257,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51.21,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,51.21,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,51.21,100,EAPG,,case rate,100% FL Medicaid EAPG,51.21,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,51.21,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,52.74,103,EAPG,,case rate,103% FL Medicaid EAPG,51.21,52.74,
"LEVEL I EYELID, LACRIMAL AND CONJUNCTIVAL PROCEDURES",258,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,882.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,882.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,882.59,100,EAPG,,case rate,100% FL Medicaid EAPG,882.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,882.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,909.07,103,EAPG,,case rate,103% FL Medicaid EAPG,882.59,909.07,
"LEVEL II EYELID, LACRIMAL AND CONJUNCTIVAL PROCEDURES",259,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1109.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1109.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1109.58,100,EAPG,,case rate,100% FL Medicaid EAPG,1109.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1109.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1142.87,103,EAPG,,case rate,103% FL Medicaid EAPG,1109.58,1142.87,
CASE MANAGEMENT AND CARE PLANNING SERVICES,260,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,82.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,82.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,82.14,100,EAPG,,case rate,100% FL Medicaid EAPG,82.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,82.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.6,103,EAPG,,case rate,103% FL Medicaid EAPG,82.14,84.6,
ESRD MONTHLY CASE MANAGEMENT,261,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,348.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,348.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,348.47,100,EAPG,,case rate,100% FL Medicaid EAPG,348.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,348.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,358.93,103,EAPG,,case rate,103% FL Medicaid EAPG,348.47,358.93,
CLEFT LIP AND PALATE REPAIR,262,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1725.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1725.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1725.29,100,EAPG,,case rate,100% FL Medicaid EAPG,1725.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1725.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1777.05,103,EAPG,,case rate,103% FL Medicaid EAPG,1725.29,1777.05,
THYROID AND PARATHYROID PROCEDURES,263,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2817.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2817.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2817.24,100,EAPG,,case rate,100% FL Medicaid EAPG,2817.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2817.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2901.75,103,EAPG,,case rate,103% FL Medicaid EAPG,2817.24,2901.75,
MAJOR CRANIOTOMY AND CRANIECTOMY SURGICAL PROCEDURES,264,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2585.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2585.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2585.96,100,EAPG,,case rate,100% FL Medicaid EAPG,2585.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2585.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2663.54,103,EAPG,,case rate,103% FL Medicaid EAPG,2585.96,2663.54,
PERCUTANEOUS INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES,265,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8906.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,8906.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,8906.89,100,EAPG,,case rate,100% FL Medicaid EAPG,8906.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,8906.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,9174.1,103,EAPG,,case rate,103% FL Medicaid EAPG,8906.89,9174.1,
OPEN INTRACRANIAL AND EXTRACRANIAL VASCULAR PROCEDURES,266,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3007.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3007.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3007.84,100,EAPG,,case rate,100% FL Medicaid EAPG,3007.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3007.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3098.07,103,EAPG,,case rate,103% FL Medicaid EAPG,3007.84,3098.07,
OTHER CRANIOTOMY PROCEDURES INCLUDING CRANIOPLASTY,267,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3921.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3921.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3921.63,100,EAPG,,case rate,100% FL Medicaid EAPG,3921.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3921.63,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4039.28,103,EAPG,,case rate,103% FL Medicaid EAPG,3921.63,4039.28,
CRANIAL AND SPINAL SHUNT PROCEDURES,268,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3617.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3617.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3617.54,100,EAPG,,case rate,100% FL Medicaid EAPG,3617.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3617.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3726.06,103,EAPG,,case rate,103% FL Medicaid EAPG,3617.54,3726.06,
LEVEL II ANCILLARY THERAPEUTIC SERVICES,269,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,22.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,22.7,100,EAPG,,case rate,100% FL Medicaid EAPG,22.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,22.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,23.38,103,EAPG,,case rate,103% FL Medicaid EAPG,22.7,23.38,
OCCUPATIONAL THERAPY,270,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,163.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,163.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,163.88,100,EAPG,,case rate,100% FL Medicaid EAPG,163.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,163.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,168.8,103,EAPG,,case rate,103% FL Medicaid EAPG,163.88,168.8,
PHYSICAL THERAPY,271,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,149.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,149.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,149.57,100,EAPG,,case rate,100% FL Medicaid EAPG,149.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,149.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,154.06,103,EAPG,,case rate,103% FL Medicaid EAPG,149.57,154.06,
SPEECH THERAPY AND EVALUATION,272,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,179.83,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,179.83,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,179.83,100,EAPG,,case rate,100% FL Medicaid EAPG,179.83,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,179.83,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,185.23,103,EAPG,,case rate,103% FL Medicaid EAPG,179.83,185.23,
PROCEDURES FOR REVISION OR REMOVAL OF NEUROSTIMULATOR DEVICES,276,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2047.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2047.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2047.4,100,EAPG,,case rate,100% FL Medicaid EAPG,2047.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2047.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2108.82,103,EAPG,,case rate,103% FL Medicaid EAPG,2047.4,2108.82,
LEVEL I VASCULAR RADIOLOGICAL PROCEDURES,277,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,724.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,724.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,724.44,100,EAPG,,case rate,100% FL Medicaid EAPG,724.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,724.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,746.18,103,EAPG,,case rate,103% FL Medicaid EAPG,724.44,746.18,
INJECTION(S) FOR RADIOLOGICAL IMAGING,278,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,221.99,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,221.99,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,221.99,100,EAPG,,case rate,100% FL Medicaid EAPG,221.99,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,221.99,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,228.65,103,EAPG,,case rate,103% FL Medicaid EAPG,221.99,228.65,
LEVEL II VASCULAR RADIOLOGICAL PROCEDURES,279,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1116.72,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1116.72,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1116.72,100,EAPG,,case rate,100% FL Medicaid EAPG,1116.72,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1116.72,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1150.22,103,EAPG,,case rate,103% FL Medicaid EAPG,1116.72,1150.22,
LEVEL III VASCULAR RADIOLOGICAL PROCEDURES,280,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2988.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2988.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2988.14,100,EAPG,,case rate,100% FL Medicaid EAPG,2988.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2988.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3077.78,103,EAPG,,case rate,103% FL Medicaid EAPG,2988.14,3077.78,
MAGNETIC RESONANCE ANGIOGRAPHY,282,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,327.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,327.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,327.92,100,EAPG,,case rate,100% FL Medicaid EAPG,327.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,327.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,337.76,103,EAPG,,case rate,103% FL Medicaid EAPG,327.92,337.76,
MYELOGRAPHY AND DISCOGRAPHY IMAGING PROCEDURES,284,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,357.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,357.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,357.48,100,EAPG,,case rate,100% FL Medicaid EAPG,357.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,357.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,368.21,103,EAPG,,case rate,103% FL Medicaid EAPG,357.48,368.21,
MAMMOGRAPHY AND OTHER RELATED PROCEDURES,286,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,30.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,30.07,100,EAPG,,case rate,100% FL Medicaid EAPG,30.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,30.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,30.97,103,EAPG,,case rate,103% FL Medicaid EAPG,30.07,30.97,
LEVEL I DIAGNOSTIC ULTRASOUND,288,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,69.97,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,69.97,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,69.97,100,EAPG,,case rate,100% FL Medicaid EAPG,69.97,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,69.97,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,72.07,103,EAPG,,case rate,103% FL Medicaid EAPG,69.97,72.07,
LEVEL II DIAGNOSTIC ULTRASOUND,289,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,106,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,106,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,106,100,EAPG,,case rate,100% FL Medicaid EAPG,106,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,106,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,109.18,103,EAPG,,case rate,103% FL Medicaid EAPG,106,109.18,
PET SCANS,290,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,895.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,895.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,895.66,100,EAPG,,case rate,100% FL Medicaid EAPG,895.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,895.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,922.53,103,EAPG,,case rate,103% FL Medicaid EAPG,895.66,922.53,
BONE DENSITY AND RELATED PROCEDURES,291,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,48.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,48.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,48.44,100,EAPG,,case rate,100% FL Medicaid EAPG,48.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,48.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,49.89,103,EAPG,,case rate,103% FL Medicaid EAPG,48.44,49.89,
MAGNETIC RESONANCE IMAGING WITHOUT CONTRAST,293,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,153.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,153.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,153.86,100,EAPG,,case rate,100% FL Medicaid EAPG,153.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,153.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,158.47,103,EAPG,,case rate,103% FL Medicaid EAPG,153.86,158.47,
MAGNETIC RESONANCE IMAGING WITH CONTRAST,295,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,258.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,258.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,258.73,100,EAPG,,case rate,100% FL Medicaid EAPG,258.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,258.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,266.49,103,EAPG,,case rate,103% FL Medicaid EAPG,258.73,266.49,
MAGNETOCEPHALOGRAPHY,297,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2132.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2132.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2132.77,100,EAPG,,case rate,100% FL Medicaid EAPG,2132.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2132.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2196.75,103,EAPG,,case rate,103% FL Medicaid EAPG,2132.77,2196.75,
LEVEL I COMPUTED TOMOGRAPHY,299,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,68.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,68.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,68.33,100,EAPG,,case rate,100% FL Medicaid EAPG,68.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,68.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,70.38,103,EAPG,,case rate,103% FL Medicaid EAPG,68.33,70.38,
LEVEL II COMPUTED TOMOGRAPHY,300,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,205.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,205.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,205.85,100,EAPG,,case rate,100% FL Medicaid EAPG,205.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,205.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,212.02,103,EAPG,,case rate,103% FL Medicaid EAPG,205.85,212.02,
COMPUTED TOMOGRAPHY- OTHER,301,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,146.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,146.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,146.8,100,EAPG,,case rate,100% FL Medicaid EAPG,146.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,146.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,151.2,103,EAPG,,case rate,103% FL Medicaid EAPG,146.8,151.2,
COMPUTED TOMOGRAPHIC ANGIOGRAPHY,302,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,253.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,253.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,253.62,100,EAPG,,case rate,100% FL Medicaid EAPG,253.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,253.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,261.23,103,EAPG,,case rate,103% FL Medicaid EAPG,253.62,261.23,
MINOR SPECIMEN COLLECTION SERVICES,304,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1.64,100,EAPG,,case rate,100% FL Medicaid EAPG,1.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1.69,103,EAPG,,case rate,103% FL Medicaid EAPG,1.64,1.69,
LEVEL I SURGICAL PATHOLOGY TESTS,305,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,20.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,20.9,100,EAPG,,case rate,100% FL Medicaid EAPG,20.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,20.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,21.53,103,EAPG,,case rate,103% FL Medicaid EAPG,20.9,21.53,
LEVEL II SURGICAL PATHOLOGY TESTS,306,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,103.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,103.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,103.04,100,EAPG,,case rate,100% FL Medicaid EAPG,103.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,103.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,106.13,103,EAPG,,case rate,103% FL Medicaid EAPG,103.04,106.13,
LEVEL III PATHOLOGY TESTS,308,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,106.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,106.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,106.86,100,EAPG,,case rate,100% FL Medicaid EAPG,106.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,106.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,110.07,103,EAPG,,case rate,103% FL Medicaid EAPG,106.86,110.07,
ADAPTIVE BEHAVIORAL HEALTH TREATMENT SERVICES,309,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,28.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,28.59,100,EAPG,,case rate,100% FL Medicaid EAPG,28.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,28.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,29.45,103,EAPG,,case rate,103% FL Medicaid EAPG,28.59,29.45,
DEVELOPMENTAL AND NEUROPSYCHOLOGICAL TESTING,310,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,394.18,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,394.18,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,394.18,100,EAPG,,case rate,100% FL Medicaid EAPG,394.18,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,394.18,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,406.01,103,EAPG,,case rate,103% FL Medicaid EAPG,394.18,406.01,
BEHAVIORAL AND SUBSTANCE ABUSE PARTIAL HOSPITALIZATION PROGRAM,312,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,337.87,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,337.87,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,337.87,100,EAPG,,case rate,100% FL Medicaid EAPG,337.87,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,337.87,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,348,103,EAPG,,case rate,103% FL Medicaid EAPG,337.87,348,
COUNSELLING OR INDIVIDUAL BRIEF PSYCHOTHERAPY,315,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,83.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.31,100,EAPG,,case rate,100% FL Medicaid EAPG,83.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.81,103,EAPG,,case rate,103% FL Medicaid EAPG,83.31,85.81,
INDIVIDUAL COMPREHENSIVE PSYCHOTHERAPY,316,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,93.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,93.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,93.76,100,EAPG,,case rate,100% FL Medicaid EAPG,93.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,93.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,96.57,103,EAPG,,case rate,103% FL Medicaid EAPG,93.76,96.57,
FAMILY PSYCHOTHERAPY,317,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,99.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.45,100,EAPG,,case rate,100% FL Medicaid EAPG,99.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,102.44,103,EAPG,,case rate,103% FL Medicaid EAPG,99.45,102.44,
GROUP PSYCHOTHERAPY,318,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,161.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,161.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,161.7,100,EAPG,,case rate,100% FL Medicaid EAPG,161.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,161.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.55,103,EAPG,,case rate,103% FL Medicaid EAPG,161.7,166.55,
ACTIVITY THERAPY,319,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,101.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.36,100,EAPG,,case rate,100% FL Medicaid EAPG,101.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,104.4,103,EAPG,,case rate,103% FL Medicaid EAPG,101.36,104.4,
BEHAVIORAL HEALTH - CASE MANAGEMENT AND TREATMENT PLAN DEVELOPMENT,320,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,61.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,61.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,61.19,100,EAPG,,case rate,100% FL Medicaid EAPG,61.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,61.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,63.03,103,EAPG,,case rate,103% FL Medicaid EAPG,61.19,63.03,
CRISIS INTERVENTION,321,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,145.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,145.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,145.47,100,EAPG,,case rate,100% FL Medicaid EAPG,145.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,145.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,149.84,103,EAPG,,case rate,103% FL Medicaid EAPG,145.47,149.84,
MEDICATION ADMINISTRATION AND OBSERVATION,322,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,22.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,22.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,22.19,100,EAPG,,case rate,100% FL Medicaid EAPG,22.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,22.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,22.86,103,EAPG,,case rate,103% FL Medicaid EAPG,22.19,22.86,
BEHAVIORAL HEALTH ASSESSMENT,323,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,153.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,153.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,153.98,100,EAPG,,case rate,100% FL Medicaid EAPG,153.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,153.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,158.6,103,EAPG,,case rate,103% FL Medicaid EAPG,153.98,158.6,
SCREENING FOR BEHAVIORAL CHANGE OR RISK ASSESSMENT,324,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,14.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,14.31,100,EAPG,,case rate,100% FL Medicaid EAPG,14.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,14.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,14.74,103,EAPG,,case rate,103% FL Medicaid EAPG,14.31,14.74,
PREVENTION COUNSELING,325,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,42.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,42.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,42.04,100,EAPG,,case rate,100% FL Medicaid EAPG,42.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,42.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,43.3,103,EAPG,,case rate,103% FL Medicaid EAPG,42.04,43.3,
INTENSIVE OUTPATIENT PSYCHIATRIC TREATMENT,327,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,211.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,211.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,211.39,100,EAPG,,case rate,100% FL Medicaid EAPG,211.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,211.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,217.73,103,EAPG,,case rate,103% FL Medicaid EAPG,211.39,217.73,
"DAY REHABILITATION, HALF DAY",328,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,206.43,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,206.43,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,206.43,100,EAPG,,case rate,100% FL Medicaid EAPG,206.43,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,206.43,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,212.63,103,EAPG,,case rate,103% FL Medicaid EAPG,206.43,212.63,
"DAY REHABILITATION, FULL DAY",329,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,307.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,307.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,307.56,100,EAPG,,case rate,100% FL Medicaid EAPG,307.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,307.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,316.79,103,EAPG,,case rate,103% FL Medicaid EAPG,307.56,316.79,
LEVEL I DIAGNOSTIC NUCLEAR MEDICINE,331,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,236.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,236.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,236.93,100,EAPG,,case rate,100% FL Medicaid EAPG,236.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,236.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,244.04,103,EAPG,,case rate,103% FL Medicaid EAPG,236.93,244.04,
LEVEL II DIAGNOSTIC NUCLEAR MEDICINE,332,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,583.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,583.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,583.92,100,EAPG,,case rate,100% FL Medicaid EAPG,583.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,583.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,601.44,103,EAPG,,case rate,103% FL Medicaid EAPG,583.92,601.44,
BEHAVIORAL HEALTH RESIDENTIAL TREATMENT,333,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,341.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,341.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,341.73,100,EAPG,,case rate,100% FL Medicaid EAPG,341.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,341.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,351.98,103,EAPG,,case rate,103% FL Medicaid EAPG,341.73,351.98,
CLASS I BRACHYTHERAPY SOURCES,335,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,166.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.57,100,EAPG,,case rate,100% FL Medicaid EAPG,166.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,171.57,103,EAPG,,case rate,103% FL Medicaid EAPG,166.57,171.57,
CLASS II BRACHYTHERAPY SOURCES,336,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2113.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2113.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2113.78,100,EAPG,,case rate,100% FL Medicaid EAPG,2113.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2113.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2177.19,103,EAPG,,case rate,103% FL Medicaid EAPG,2113.78,2177.19,
CLASS III BRACHYTHERAPY SOURCES,337,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7779.06,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7779.06,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7779.06,100,EAPG,,case rate,100% FL Medicaid EAPG,7779.06,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7779.06,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,8012.43,103,EAPG,,case rate,103% FL Medicaid EAPG,7779.06,8012.43,
THERAPEUTIC NUCLEAR MEDICINE,340,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,155.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,155.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,155.34,100,EAPG,,case rate,100% FL Medicaid EAPG,155.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,155.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,160,103,EAPG,,case rate,103% FL Medicaid EAPG,155.34,160,
LEVEL I RADIATION THERAPY,343,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,115.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.05,100,EAPG,,case rate,100% FL Medicaid EAPG,115.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,118.5,103,EAPG,,case rate,103% FL Medicaid EAPG,115.05,118.5,
RADIOSURGERY,346,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3346.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3346.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3346.13,100,EAPG,,case rate,100% FL Medicaid EAPG,3346.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3346.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3446.51,103,EAPG,,case rate,103% FL Medicaid EAPG,3346.13,3446.51,
LEVEL II RADIATION THERAPY,347,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,305.18,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,305.18,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,305.18,100,EAPG,,case rate,100% FL Medicaid EAPG,305.18,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,305.18,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,314.34,103,EAPG,,case rate,103% FL Medicaid EAPG,305.18,314.34,
LEVEL III RADIATION THERAPY,348,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,896.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,896.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,896.36,100,EAPG,,case rate,100% FL Medicaid EAPG,896.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,896.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,923.25,103,EAPG,,case rate,103% FL Medicaid EAPG,896.36,923.25,
ADJUNCTIVE DENTAL SERVICES,350,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,152.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,152.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,152.38,100,EAPG,,case rate,100% FL Medicaid EAPG,152.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,152.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,156.95,103,EAPG,,case rate,103% FL Medicaid EAPG,152.38,156.95,
LEVEL I PERIODONTICS,352,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,596.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,596.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,596.64,100,EAPG,,case rate,100% FL Medicaid EAPG,596.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,596.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,614.54,103,EAPG,,case rate,103% FL Medicaid EAPG,596.64,614.54,
"LEVEL I PROSTHODONTICS, FIXED",353,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,67.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,67.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,67.24,100,EAPG,,case rate,100% FL Medicaid EAPG,67.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,67.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,69.25,103,EAPG,,case rate,103% FL Medicaid EAPG,67.24,69.25,
"LEVEL II PROSTHODONTICS, FIXED",354,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,251.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,251.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,251.52,100,EAPG,,case rate,100% FL Medicaid EAPG,251.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,251.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,259.06,103,EAPG,,case rate,103% FL Medicaid EAPG,251.52,259.06,
"LEVEL III PROSTHODONTICS, FIXED",355,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,311.15,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,311.15,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,311.15,100,EAPG,,case rate,100% FL Medicaid EAPG,311.15,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,311.15,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,320.48,103,EAPG,,case rate,103% FL Medicaid EAPG,311.15,320.48,
"LEVEL I PROSTHODONTICS, REMOVABLE",356,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,136.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,136.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,136.27,100,EAPG,,case rate,100% FL Medicaid EAPG,136.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,136.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,140.36,103,EAPG,,case rate,103% FL Medicaid EAPG,136.27,140.36,
"LEVEL II PROSTHODONTICS, REMOVABLE",357,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,168.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,168.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,168.48,100,EAPG,,case rate,100% FL Medicaid EAPG,168.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,168.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,173.54,103,EAPG,,case rate,103% FL Medicaid EAPG,168.48,173.54,
"LEVEL III PROSTHODONTICS, REMOVABLE",358,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,200.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,200.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,200.66,100,EAPG,,case rate,100% FL Medicaid EAPG,200.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,200.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,206.68,103,EAPG,,case rate,103% FL Medicaid EAPG,200.66,206.68,
LEVEL I MAXILLOFACIAL PROSTHETICS,359,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1003.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1003.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1003.26,100,EAPG,,case rate,100% FL Medicaid EAPG,1003.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1003.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1033.36,103,EAPG,,case rate,103% FL Medicaid EAPG,1003.26,1033.36,
LEVEL II MAXILLOFACIAL PROSTHETICS,360,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2155.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2155.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2155.86,100,EAPG,,case rate,100% FL Medicaid EAPG,2155.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2155.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2220.53,103,EAPG,,case rate,103% FL Medicaid EAPG,2155.86,2220.53,
LEVEL I DENTAL RESTORATIONS,361,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1409.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1409.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1409.85,100,EAPG,,case rate,100% FL Medicaid EAPG,1409.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1409.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1452.14,103,EAPG,,case rate,103% FL Medicaid EAPG,1409.85,1452.14,
LEVEL II DENTAL RESTORATIONS,362,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1881.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1881.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1881.33,100,EAPG,,case rate,100% FL Medicaid EAPG,1881.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1881.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1937.77,103,EAPG,,case rate,103% FL Medicaid EAPG,1881.33,1937.77,
LEVEL III DENTAL RESTORATIONS,363,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1795.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1795.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1795.68,100,EAPG,,case rate,100% FL Medicaid EAPG,1795.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1795.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1849.55,103,EAPG,,case rate,103% FL Medicaid EAPG,1795.68,1849.55,
LEVEL I ENDODONTICS,364,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,92.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,92.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,92.35,100,EAPG,,case rate,100% FL Medicaid EAPG,92.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,92.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,95.12,103,EAPG,,case rate,103% FL Medicaid EAPG,92.35,95.12,
LEVEL II ENDODONTICS,365,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,166.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.11,100,EAPG,,case rate,100% FL Medicaid EAPG,166.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,171.09,103,EAPG,,case rate,103% FL Medicaid EAPG,166.11,171.09,
LEVEL III ENDODONTICS,366,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,197.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,197.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,197.89,100,EAPG,,case rate,100% FL Medicaid EAPG,197.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,197.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,203.83,103,EAPG,,case rate,103% FL Medicaid EAPG,197.89,203.83,
LEVEL I ORAL SURGERY PROCEDURES,367,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,805.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,805.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,805.76,100,EAPG,,case rate,100% FL Medicaid EAPG,805.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,805.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,829.93,103,EAPG,,case rate,103% FL Medicaid EAPG,805.76,829.93,
LEVEL II ORAL SURGERY PROCEDURES,368,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1242.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1242.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1242.45,100,EAPG,,case rate,100% FL Medicaid EAPG,1242.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1242.45,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1279.73,103,EAPG,,case rate,103% FL Medicaid EAPG,1242.45,1279.73,
LEVEL III ORAL SURGERY PROCEDURES,369,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1874.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1874.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1874.04,100,EAPG,,case rate,100% FL Medicaid EAPG,1874.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1874.04,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1930.26,103,EAPG,,case rate,103% FL Medicaid EAPG,1874.04,1930.26,
LEVEL I ORTHODONTICS,371,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,887.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,887.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,887.47,100,EAPG,,case rate,100% FL Medicaid EAPG,887.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,887.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,914.09,103,EAPG,,case rate,103% FL Medicaid EAPG,887.47,914.09,
SEALANT,372,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,32.72,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,32.72,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,32.72,100,EAPG,,case rate,100% FL Medicaid EAPG,32.72,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,32.72,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,33.7,103,EAPG,,case rate,103% FL Medicaid EAPG,32.72,33.7,
LEVEL I DENTAL IMAGING,373,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,24.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,24.26,100,EAPG,,case rate,100% FL Medicaid EAPG,24.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,24.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,24.99,103,EAPG,,case rate,103% FL Medicaid EAPG,24.26,24.99,
LEVEL II DENTAL IMAGING,374,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,92.67,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,92.67,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,92.67,100,EAPG,,case rate,100% FL Medicaid EAPG,92.67,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,92.67,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,95.45,103,EAPG,,case rate,103% FL Medicaid EAPG,92.67,95.45,
DENTAL ANESTHESIA,375,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27.65,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,27.65,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,27.65,100,EAPG,,case rate,100% FL Medicaid EAPG,27.65,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,27.65,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,28.48,103,EAPG,,case rate,103% FL Medicaid EAPG,27.65,28.48,
DIAGNOSTIC DENTAL PROCEDURES,376,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,83.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.07,100,EAPG,,case rate,100% FL Medicaid EAPG,83.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.56,103,EAPG,,case rate,103% FL Medicaid EAPG,83.07,85.56,
PREVENTIVE DENTAL PROCEDURES,377,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,87.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.25,100,EAPG,,case rate,100% FL Medicaid EAPG,87.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,89.86,103,EAPG,,case rate,103% FL Medicaid EAPG,87.25,89.86,
LEVEL II PERIODONTICS,378,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,884.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,884.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,884.82,100,EAPG,,case rate,100% FL Medicaid EAPG,884.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,884.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,911.36,103,EAPG,,case rate,103% FL Medicaid EAPG,884.82,911.36,
LEVEL II ORTHODONTICS,379,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,976.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,976.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,976.23,100,EAPG,,case rate,100% FL Medicaid EAPG,976.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,976.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1005.52,103,EAPG,,case rate,103% FL Medicaid EAPG,976.23,1005.52,
ANESTHESIA,380,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,14,100,EAPG,,case rate,100% FL Medicaid EAPG,14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,14.42,103,EAPG,,case rate,103% FL Medicaid EAPG,14,14.42,
LEVEL I DENTAL IMPLANTS,381,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,851.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,851.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,851.74,100,EAPG,,case rate,100% FL Medicaid EAPG,851.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,851.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,877.3,103,EAPG,,case rate,103% FL Medicaid EAPG,851.74,877.3,
LEVEL II DENTAL IMPLANTS,382,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,936.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,936.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,936.92,100,EAPG,,case rate,100% FL Medicaid EAPG,936.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,936.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,965.03,103,EAPG,,case rate,103% FL Medicaid EAPG,936.92,965.03,
LEVEL III CHEMISTRY TESTS,384,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,35.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,35.92,100,EAPG,,case rate,100% FL Medicaid EAPG,35.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,35.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,37,103,EAPG,,case rate,103% FL Medicaid EAPG,35.92,37,
"LEVEL I COMPLEX LABORATORY, MOLECULAR PATHOLOGY AND GENETIC TESTS",385,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,23.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,23.05,100,EAPG,,case rate,100% FL Medicaid EAPG,23.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,23.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,23.74,103,EAPG,,case rate,103% FL Medicaid EAPG,23.05,23.74,
"LEVEL II COMPLEX LABORATORY, MOLECULAR PATHOLOGY AND GENETIC TESTS",386,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,84.75,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.75,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.75,100,EAPG,,case rate,100% FL Medicaid EAPG,84.75,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.75,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.29,103,EAPG,,case rate,103% FL Medicaid EAPG,84.75,87.29,
"LEVEL III COMPLEX LABORATORY, MOLECULAR PATHOLOGY AND GENETIC TESTS",387,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,188.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,188.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,188.92,100,EAPG,,case rate,100% FL Medicaid EAPG,188.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,188.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,194.59,103,EAPG,,case rate,103% FL Medicaid EAPG,188.92,194.59,
LEVEL III MICROBIOLOGY TESTS,388,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,95.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,95.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,95.28,100,EAPG,,case rate,100% FL Medicaid EAPG,95.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,95.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.14,103,EAPG,,case rate,103% FL Medicaid EAPG,95.28,98.14,
LEVEL II CONVENTIONAL RADIOLOGY,389,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,74.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,74.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,74.61,100,EAPG,,case rate,100% FL Medicaid EAPG,74.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,74.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,76.85,103,EAPG,,case rate,103% FL Medicaid EAPG,74.61,76.85,
LEVEL I PATHOLOGY TESTS,390,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2.61,100,EAPG,,case rate,100% FL Medicaid EAPG,2.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2.69,103,EAPG,,case rate,103% FL Medicaid EAPG,2.61,2.69,
LEVEL II PATHOLOGY TESTS,391,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,21.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,21.02,100,EAPG,,case rate,100% FL Medicaid EAPG,21.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,21.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,21.65,103,EAPG,,case rate,103% FL Medicaid EAPG,21.02,21.65,
PAP SMEARS,392,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10.8,100,EAPG,,case rate,100% FL Medicaid EAPG,10.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,11.13,103,EAPG,,case rate,103% FL Medicaid EAPG,10.8,11.13,
LEVEL II BLOOD AND TISSUE TYPING TESTS,393,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,32.6,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,32.6,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,32.6,100,EAPG,,case rate,100% FL Medicaid EAPG,32.6,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,32.6,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,33.58,103,EAPG,,case rate,103% FL Medicaid EAPG,32.6,33.58,
LEVEL I IMMUNOLOGY TESTS,394,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.97,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5.97,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5.97,100,EAPG,,case rate,100% FL Medicaid EAPG,5.97,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5.97,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6.15,103,EAPG,,case rate,103% FL Medicaid EAPG,5.97,6.15,
LEVEL II IMMUNOLOGY TESTS,395,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,21.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,21.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,21.57,100,EAPG,,case rate,100% FL Medicaid EAPG,21.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,21.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,22.21,103,EAPG,,case rate,103% FL Medicaid EAPG,21.57,22.21,
LEVEL I MICROBIOLOGY TESTS,396,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5.23,100,EAPG,,case rate,100% FL Medicaid EAPG,5.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5.38,103,EAPG,,case rate,103% FL Medicaid EAPG,5.23,5.38,
LEVEL II MICROBIOLOGY TESTS,397,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,30.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,30.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,30.81,100,EAPG,,case rate,100% FL Medicaid EAPG,30.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,30.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,31.74,103,EAPG,,case rate,103% FL Medicaid EAPG,30.81,31.74,
LEVEL I ENDOCRINOLOGY TESTS,398,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7.02,100,EAPG,,case rate,100% FL Medicaid EAPG,7.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7.23,103,EAPG,,case rate,103% FL Medicaid EAPG,7.02,7.23,
LEVEL II ENDOCRINOLOGY TESTS,399,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,18.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,18.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,18.41,100,EAPG,,case rate,100% FL Medicaid EAPG,18.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,18.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,18.96,103,EAPG,,case rate,103% FL Medicaid EAPG,18.41,18.96,
LEVEL I CHEMISTRY TESTS,400,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6.4,100,EAPG,,case rate,100% FL Medicaid EAPG,6.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6.59,103,EAPG,,case rate,103% FL Medicaid EAPG,6.4,6.59,
LEVEL II CHEMISTRY TESTS,401,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,14.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,14.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,14.86,100,EAPG,,case rate,100% FL Medicaid EAPG,14.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,14.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,15.31,103,EAPG,,case rate,103% FL Medicaid EAPG,14.86,15.31,
BASIC CHEMISTRY TESTS,402,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2.89,100,EAPG,,case rate,100% FL Medicaid EAPG,2.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2.97,103,EAPG,,case rate,103% FL Medicaid EAPG,2.89,2.97,
ORGAN OR DISEASE ORIENTED PANELS,403,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4.8,100,EAPG,,case rate,100% FL Medicaid EAPG,4.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4.94,103,EAPG,,case rate,103% FL Medicaid EAPG,4.8,4.94,
TOXICOLOGY TESTS,404,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6.44,100,EAPG,,case rate,100% FL Medicaid EAPG,6.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6.63,103,EAPG,,case rate,103% FL Medicaid EAPG,6.44,6.63,
THERAPEUTIC DRUG MONITORING,405,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,6.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6.44,100,EAPG,,case rate,100% FL Medicaid EAPG,6.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,6.63,103,EAPG,,case rate,103% FL Medicaid EAPG,6.44,6.63,
LEVEL I CLOTTING TESTS,406,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2.34,100,EAPG,,case rate,100% FL Medicaid EAPG,2.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2.41,103,EAPG,,case rate,103% FL Medicaid EAPG,2.34,2.41,
LEVEL II CLOTTING TESTS,407,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,13.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,13.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,13.57,100,EAPG,,case rate,100% FL Medicaid EAPG,13.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,13.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,13.98,103,EAPG,,case rate,103% FL Medicaid EAPG,13.57,13.98,
LEVEL I HEMATOLOGY TESTS,408,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3.16,100,EAPG,,case rate,100% FL Medicaid EAPG,3.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3.25,103,EAPG,,case rate,103% FL Medicaid EAPG,3.16,3.25,
URINALYSIS,410,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1.56,100,EAPG,,case rate,100% FL Medicaid EAPG,1.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1.61,103,EAPG,,case rate,103% FL Medicaid EAPG,1.56,1.61,
ANCILLARY RESPIRATORY THERAPY AND OTHER PULMONARY TESTS AND SERVICES,412,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,37.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,37.25,100,EAPG,,case rate,100% FL Medicaid EAPG,37.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,37.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,38.36,103,EAPG,,case rate,103% FL Medicaid EAPG,37.25,38.36,
CARDIOGRAM,413,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.69,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,16.69,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,16.69,100,EAPG,,case rate,100% FL Medicaid EAPG,16.69,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,16.69,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,17.19,103,EAPG,,case rate,103% FL Medicaid EAPG,16.69,17.19,
LEVEL I IMMUNIZATION,414,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,16.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,16.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,16.34,100,EAPG,,case rate,100% FL Medicaid EAPG,16.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,16.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,16.83,103,EAPG,,case rate,103% FL Medicaid EAPG,16.34,16.83,
LEVEL II IMMUNIZATION,415,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,78.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,78.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,78.9,100,EAPG,,case rate,100% FL Medicaid EAPG,78.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,78.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,81.27,103,EAPG,,case rate,103% FL Medicaid EAPG,78.9,81.27,
MINOR FEMALE REPRODUCTIVE PROCEDURES,417,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,140.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,140.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,140.13,100,EAPG,,case rate,100% FL Medicaid EAPG,140.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,140.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,144.33,103,EAPG,,case rate,103% FL Medicaid EAPG,140.13,144.33,
AMBULATORY PATIENT MONITORING AND RELATED ASSESSMENTS,418,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37.67,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,37.67,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,37.67,100,EAPG,,case rate,100% FL Medicaid EAPG,37.67,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,37.67,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,38.81,103,EAPG,,case rate,103% FL Medicaid EAPG,37.67,38.81,
ANCILLARY OPHTHALMOLOGY OR OPTOMETRY SERVICES,419,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,51.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,51.4,100,EAPG,,case rate,100% FL Medicaid EAPG,51.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,51.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,52.95,103,EAPG,,case rate,103% FL Medicaid EAPG,51.4,52.95,
"ELECTRONIC ANALYSIS FOR CARDIAC, NEUROLOGICAL AND OTHER DEVICES",420,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,88.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.42,100,EAPG,,case rate,100% FL Medicaid EAPG,88.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.07,103,EAPG,,case rate,103% FL Medicaid EAPG,88.42,91.07,
VASCULAR ACCESS BY NEEDLE OR CATHETER,423,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,431.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,431.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,431.35,100,EAPG,,case rate,100% FL Medicaid EAPG,431.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,431.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,444.29,103,EAPG,,case rate,103% FL Medicaid EAPG,431.35,444.29,
BIOFEEDBACK AND OTHER TRAINING,427,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,62.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,62.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,62.28,100,EAPG,,case rate,100% FL Medicaid EAPG,62.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,62.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,64.15,103,EAPG,,case rate,103% FL Medicaid EAPG,62.28,64.15,
"PATIENT EDUCATION, INDIVIDUAL",428,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,44.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,44.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,44.34,100,EAPG,,case rate,100% FL Medicaid EAPG,44.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,44.34,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,45.67,103,EAPG,,case rate,103% FL Medicaid EAPG,44.34,45.67,
"PATIENT EDUCATION, GROUP",429,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,27.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,27.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,27.46,100,EAPG,,case rate,100% FL Medicaid EAPG,27.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,27.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,28.28,103,EAPG,,case rate,103% FL Medicaid EAPG,27.46,28.28,
CLASS II CHEMOTHERAPY DRUGS,431,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,28.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,28.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,28.12,100,EAPG,,case rate,100% FL Medicaid EAPG,28.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,28.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,28.96,103,EAPG,,case rate,103% FL Medicaid EAPG,28.12,28.96,
CLASS III CHEMOTHERAPY DRUGS,432,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,72.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,72.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,72.19,100,EAPG,,case rate,100% FL Medicaid EAPG,72.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,72.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,74.36,103,EAPG,,case rate,103% FL Medicaid EAPG,72.19,74.36,
CLASS IV CHEMOTHERAPY DRUGS,433,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,75.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,75.82,100,EAPG,,case rate,100% FL Medicaid EAPG,75.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,75.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,78.09,103,EAPG,,case rate,103% FL Medicaid EAPG,75.82,78.09,
CLASS V CHEMOTHERAPY DRUGS,434,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,220.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,220.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,220.59,100,EAPG,,case rate,100% FL Medicaid EAPG,220.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,220.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,227.21,103,EAPG,,case rate,103% FL Medicaid EAPG,220.59,227.21,
CLASS II PHARMACOTHERAPY,436,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,68.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,68.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,68.49,100,EAPG,,case rate,100% FL Medicaid EAPG,68.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,68.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,70.54,103,EAPG,,case rate,103% FL Medicaid EAPG,68.49,70.54,
CLASS III PHARMACOTHERAPY,437,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,77.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,77.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,77.07,100,EAPG,,case rate,100% FL Medicaid EAPG,77.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,77.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,79.38,103,EAPG,,case rate,103% FL Medicaid EAPG,77.07,79.38,
CLASS IV PHARMACOTHERAPY,438,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,122.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,122.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,122.62,100,EAPG,,case rate,100% FL Medicaid EAPG,122.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,122.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.3,103,EAPG,,case rate,103% FL Medicaid EAPG,122.62,126.3,
CLASS V PHARMACOTHERAPY,439,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,308.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,308.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,308.54,100,EAPG,,case rate,100% FL Medicaid EAPG,308.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,308.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,317.79,103,EAPG,,case rate,103% FL Medicaid EAPG,308.54,317.79,
CLASS VI PHARMACOTHERAPY,440,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,322.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,322.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,322.19,100,EAPG,,case rate,100% FL Medicaid EAPG,322.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,322.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,331.85,103,EAPG,,case rate,103% FL Medicaid EAPG,322.19,331.85,
CLASS VI CHEMOTHERAPY DRUGS,441,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,392,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,392,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,392,100,EAPG,,case rate,100% FL Medicaid EAPG,392,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,392,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,403.76,103,EAPG,,case rate,103% FL Medicaid EAPG,392,403.76,
CLASS VII CHEMOTHERAPY DRUGS,443,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,711.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,711.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,711.11,100,EAPG,,case rate,100% FL Medicaid EAPG,711.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,711.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,732.44,103,EAPG,,case rate,103% FL Medicaid EAPG,711.11,732.44,
CLASS VII PHARMACOTHERAPY,444,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,614.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,614.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,614.07,100,EAPG,,case rate,100% FL Medicaid EAPG,614.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,614.07,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,632.49,103,EAPG,,case rate,103% FL Medicaid EAPG,614.07,632.49,
EXPANDED HOURS ACCESS,448,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26.17,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,26.17,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,26.17,100,EAPG,,case rate,100% FL Medicaid EAPG,26.17,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,26.17,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,26.95,103,EAPG,,case rate,103% FL Medicaid EAPG,26.17,26.95,
OBSERVATION,450,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,551.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,551.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,551.71,100,EAPG,,case rate,100% FL Medicaid EAPG,551.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,551.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,568.26,103,EAPG,,case rate,103% FL Medicaid EAPG,551.71,568.26,
ALLERGY THERAPY,458,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,15.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,15.13,100,EAPG,,case rate,100% FL Medicaid EAPG,15.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,15.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,15.59,103,EAPG,,case rate,103% FL Medicaid EAPG,15.13,15.59,
VACCINE ADMINISTRATION,459,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,25.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,25.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,25.58,100,EAPG,,case rate,100% FL Medicaid EAPG,25.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,25.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,26.35,103,EAPG,,case rate,103% FL Medicaid EAPG,25.58,26.35,
CLASS VIII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY,460,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,798.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,798.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,798.16,100,EAPG,,case rate,100% FL Medicaid EAPG,798.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,798.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,822.1,103,EAPG,,case rate,103% FL Medicaid EAPG,798.16,822.1,
CLASS IX COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY,461,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1116.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1116.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1116.91,100,EAPG,,case rate,100% FL Medicaid EAPG,1116.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1116.91,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1150.42,103,EAPG,,case rate,103% FL Medicaid EAPG,1116.91,1150.42,
CLASS X COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY,462,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2759.75,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2759.75,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2759.75,100,EAPG,,case rate,100% FL Medicaid EAPG,2759.75,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2759.75,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2842.54,103,EAPG,,case rate,103% FL Medicaid EAPG,2759.75,2842.54,
CLASS XI COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY,463,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3075.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3075.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3075.81,100,EAPG,,case rate,100% FL Medicaid EAPG,3075.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3075.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3168.09,103,EAPG,,case rate,103% FL Medicaid EAPG,3075.81,3168.09,
CLASS XII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY,464,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4890.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4890.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4890.41,100,EAPG,,case rate,100% FL Medicaid EAPG,4890.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4890.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5037.13,103,EAPG,,case rate,103% FL Medicaid EAPG,4890.41,5037.13,
CLASS XIII COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY,465,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,10712.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10712.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10712.95,100,EAPG,,case rate,100% FL Medicaid EAPG,10712.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,10712.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,11034.34,103,EAPG,,case rate,103% FL Medicaid EAPG,10712.95,11034.34,
CLASS XIV COMBINED CHEMOTHERAPY AND PHARMACOTHERAPY,466,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,15400.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,15400.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,15400.68,100,EAPG,,case rate,100% FL Medicaid EAPG,15400.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,15400.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,15862.7,103,EAPG,,case rate,103% FL Medicaid EAPG,15400.68,15862.7,
OBSTETRICAL ULTRASOUND,470,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,64.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,64.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,64.16,100,EAPG,,case rate,100% FL Medicaid EAPG,64.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,64.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,66.08,103,EAPG,,case rate,103% FL Medicaid EAPG,64.16,66.08,
LEVEL I CONVENTIONAL RADIOLOGY,471,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,35.69,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,35.69,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,35.69,100,EAPG,,case rate,100% FL Medicaid EAPG,35.69,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,35.69,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,36.76,103,EAPG,,case rate,103% FL Medicaid EAPG,35.69,36.76,
ULTRASOUND GUIDANCE,472,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,69.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,69.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,69.5,100,EAPG,,case rate,100% FL Medicaid EAPG,69.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,69.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,71.58,103,EAPG,,case rate,103% FL Medicaid EAPG,69.5,71.58,
CT GUIDANCE,473,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,51.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,51.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,51.48,100,EAPG,,case rate,100% FL Medicaid EAPG,51.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,51.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,53.03,103,EAPG,,case rate,103% FL Medicaid EAPG,51.48,53.03,
RADIOLOGICAL GUIDANCE FOR THERAPEUTIC OR DIAGNOSTIC PROCEDURES,474,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,131.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,131.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,131.24,100,EAPG,,case rate,100% FL Medicaid EAPG,131.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,131.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,135.18,103,EAPG,,case rate,103% FL Medicaid EAPG,131.24,135.18,
MRI GUIDANCE,475,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,134.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,134.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,134.4,100,EAPG,,case rate,100% FL Medicaid EAPG,134.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,134.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,138.43,103,EAPG,,case rate,103% FL Medicaid EAPG,134.4,138.43,
LEVEL I RADIATION TREATMENT PREPARATION AND PLANNING,476,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,76.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,76.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,76.68,100,EAPG,,case rate,100% FL Medicaid EAPG,76.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,76.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,78.98,103,EAPG,,case rate,103% FL Medicaid EAPG,76.68,78.98,
LEVEL II RADIATION TREATMENT PREPARATION AND PLANNING,477,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,114.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,114.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,114.12,100,EAPG,,case rate,100% FL Medicaid EAPG,114.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,114.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,117.54,103,EAPG,,case rate,103% FL Medicaid EAPG,114.12,117.54,
LEVEL III RADIATION TREATMENT PREPARATION AND PLANNING,478,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,679.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,679.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,679.2,100,EAPG,,case rate,100% FL Medicaid EAPG,679.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,679.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,699.58,103,EAPG,,case rate,103% FL Medicaid EAPG,679.2,699.58,
RADIATION THERAPY MANAGEMENT,483,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,251.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,251.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,251.13,100,EAPG,,case rate,100% FL Medicaid EAPG,251.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,251.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,258.66,103,EAPG,,case rate,103% FL Medicaid EAPG,251.13,258.66,
CORNEAL TISSUE PROCESSING,485,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1741.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1741.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1741.82,100,EAPG,,case rate,100% FL Medicaid EAPG,1741.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1741.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1794.08,103,EAPG,,case rate,103% FL Medicaid EAPG,1741.82,1794.08,
LEVEL I BLOOD AND TISSUE TYPING TESTS,486,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2.3,100,EAPG,,case rate,100% FL Medicaid EAPG,2.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2.37,103,EAPG,,case rate,103% FL Medicaid EAPG,2.3,2.37,
MINOR DEVICE EVALUATION AND INTERROGATION,488,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,23.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,23.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,23.05,100,EAPG,,case rate,100% FL Medicaid EAPG,23.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,23.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,23.74,103,EAPG,,case rate,103% FL Medicaid EAPG,23.05,23.74,
LEVEL I ANCILLARY THERAPEUTIC SERVICES,493,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,17.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,17.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,17.98,100,EAPG,,case rate,100% FL Medicaid EAPG,17.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,17.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,18.52,103,EAPG,,case rate,103% FL Medicaid EAPG,17.98,18.52,
COMPLEX BLOOD COLLECTION SERVICES,494,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,45.83,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,45.83,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,45.83,100,EAPG,,case rate,100% FL Medicaid EAPG,45.83,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,45.83,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,47.2,103,EAPG,,case rate,103% FL Medicaid EAPG,45.83,47.2,
TELEHEALTH FACILITATION,497,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7.57,100,EAPG,,case rate,100% FL Medicaid EAPG,7.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7.79,103,EAPG,,case rate,103% FL Medicaid EAPG,7.57,7.79,
"BLOOD PROCESSING, STORAGE AND RELATED SERVICES",499,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,55.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,55.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,55.19,100,EAPG,,case rate,100% FL Medicaid EAPG,55.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,55.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,56.84,103,EAPG,,case rate,103% FL Medicaid EAPG,55.19,56.84,
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,518,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,138.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,138.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,138.3,100,EAPG,,case rate,100% FL Medicaid EAPG,138.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,138.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,142.45,103,EAPG,,case rate,103% FL Medicaid EAPG,138.3,142.45,
NON-BACTERIAL INFECTIONS OF NERVOUS SYSTEM,519,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,87.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.01,100,EAPG,,case rate,100% FL Medicaid EAPG,87.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,89.62,103,EAPG,,case rate,103% FL Medicaid EAPG,87.01,89.62,
SPINAL DIAGNOSES AND INJURIES,520,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,97.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,97.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,97.46,100,EAPG,,case rate,100% FL Medicaid EAPG,97.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,97.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,100.39,103,EAPG,,case rate,103% FL Medicaid EAPG,97.46,100.39,
NERVOUS SYSTEM MALIGNANCY,521,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,89.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,89.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,89.16,100,EAPG,,case rate,100% FL Medicaid EAPG,89.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,89.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.83,103,EAPG,,case rate,103% FL Medicaid EAPG,89.16,91.83,
DEGENERATIVE NERVOUS SYSTEM DIAGNOSES EXC MULT SCLEROSIS,522,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,84.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.71,100,EAPG,,case rate,100% FL Medicaid EAPG,84.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.25,103,EAPG,,case rate,103% FL Medicaid EAPG,84.71,87.25,
MULTIPLE SCLEROSIS AND OTHER DEMYELINATING DISEASES,523,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,76.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,76.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,76.29,100,EAPG,,case rate,100% FL Medicaid EAPG,76.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,76.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,78.57,103,EAPG,,case rate,103% FL Medicaid EAPG,76.29,78.57,
OTHER CENTRAL NERVOUS SYSTEM DIAGNOSES,524,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,102.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,102.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,102.77,100,EAPG,,case rate,100% FL Medicaid EAPG,102.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,102.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,105.85,103,EAPG,,case rate,103% FL Medicaid EAPG,102.77,105.85,
TRANSIENT ISCHEMIA,526,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,168.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,168.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,168.02,100,EAPG,,case rate,100% FL Medicaid EAPG,168.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,168.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,173.06,103,EAPG,,case rate,103% FL Medicaid EAPG,168.02,173.06,
"PERIPHERAL, CRANIAL AND AUTONOMIC NERVE DIAGNOSES",527,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,85.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.41,100,EAPG,,case rate,100% FL Medicaid EAPG,85.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.97,103,EAPG,,case rate,103% FL Medicaid EAPG,85.41,87.97,
ANOXIC AND OTHER SEVERE BRAIN DAMAGE OR COMA,528,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,117.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,117.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,117.24,100,EAPG,,case rate,100% FL Medicaid EAPG,117.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,117.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,120.75,103,EAPG,,case rate,103% FL Medicaid EAPG,117.24,120.75,
SEIZURE,529,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,127.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,127.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,127.77,100,EAPG,,case rate,100% FL Medicaid EAPG,127.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,127.77,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,131.6,103,EAPG,,case rate,103% FL Medicaid EAPG,127.77,131.6,
HEADACHES OTHER THAN MIGRAINE,530,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,109.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,109.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,109.09,100,EAPG,,case rate,100% FL Medicaid EAPG,109.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,109.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,112.36,103,EAPG,,case rate,103% FL Medicaid EAPG,109.09,112.36,
MIGRAINE,531,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,79.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,79.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,79.68,100,EAPG,,case rate,100% FL Medicaid EAPG,79.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,79.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,82.07,103,EAPG,,case rate,103% FL Medicaid EAPG,79.68,82.07,
HEAD TRAUMA WITH OR WITHOUT LOC/COMA LESS THAN 1 HR,532,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,141.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,141.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,141.11,100,EAPG,,case rate,100% FL Medicaid EAPG,141.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,141.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,145.34,103,EAPG,,case rate,103% FL Medicaid EAPG,141.11,145.34,
AFTEREFFECTS OF CEREBROVASCULAR ACCIDENT,533,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,99.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.14,100,EAPG,,case rate,100% FL Medicaid EAPG,99.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,102.11,103,EAPG,,case rate,103% FL Medicaid EAPG,99.14,102.11,
NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION W/O INFARC,534,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,78.51,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,78.51,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,78.51,100,EAPG,,case rate,100% FL Medicaid EAPG,78.51,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,78.51,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,80.86,103,EAPG,,case rate,103% FL Medicaid EAPG,78.51,80.86,
CVA AND PRECEREBRAL OCCLUSION W INFARCT,535,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,154.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,154.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,154.37,100,EAPG,,case rate,100% FL Medicaid EAPG,154.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,154.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,159,103,EAPG,,case rate,103% FL Medicaid EAPG,154.37,159,
CEREBRAL PALSY,536,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,98.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.09,100,EAPG,,case rate,100% FL Medicaid EAPG,98.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.03,103,EAPG,,case rate,103% FL Medicaid EAPG,98.09,101.03,
"MALFUNCTION, REACTION, COMPLICATION OF NEUROLOGICAL DEVICE OR PROC",537,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,113.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,113.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,113.57,100,EAPG,,case rate,100% FL Medicaid EAPG,113.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,113.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,116.98,103,EAPG,,case rate,103% FL Medicaid EAPG,113.57,116.98,
HEAD TRAUMA WITH LOC/COMA MORE THEN 1 HR,538,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,322.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,322.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,322.58,100,EAPG,,case rate,100% FL Medicaid EAPG,322.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,322.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,332.25,103,EAPG,,case rate,103% FL Medicaid EAPG,322.58,332.25,
INTRACRANIAL HEMORRHAGE,539,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,178.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,178.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,178.12,100,EAPG,,case rate,100% FL Medicaid EAPG,178.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,178.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,183.46,103,EAPG,,case rate,103% FL Medicaid EAPG,178.12,183.46,
"PERIPHERAL, CRANIAL, AND AUTONOMIC NERVE INJURIES",545,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,100.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,100.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,100.78,100,EAPG,,case rate,100% FL Medicaid EAPG,100.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,100.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,103.8,103,EAPG,,case rate,103% FL Medicaid EAPG,100.78,103.8,
PERIPHERAL AND OTHER VASCULAR RELATED INJURIES,548,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,138.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,138.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,138.14,100,EAPG,,case rate,100% FL Medicaid EAPG,138.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,138.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,142.29,103,EAPG,,case rate,103% FL Medicaid EAPG,138.14,142.29,
ACUTE MAJOR EYE INFECTIONS,550,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,88.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.84,100,EAPG,,case rate,100% FL Medicaid EAPG,88.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.51,103,EAPG,,case rate,103% FL Medicaid EAPG,88.84,91.51,
CATARACTS,551,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,70.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,70.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,70.16,100,EAPG,,case rate,100% FL Medicaid EAPG,70.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,70.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,72.27,103,EAPG,,case rate,103% FL Medicaid EAPG,70.16,72.27,
GLAUCOMA,552,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,85.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.76,100,EAPG,,case rate,100% FL Medicaid EAPG,85.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.34,103,EAPG,,case rate,103% FL Medicaid EAPG,85.76,88.34,
OTHER OPHTHALMIC SYSTEM DIAGNOSES,553,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,98.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.48,100,EAPG,,case rate,100% FL Medicaid EAPG,98.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.43,103,EAPG,,case rate,103% FL Medicaid EAPG,98.48,101.43,
CONJUNCTIVITIS,555,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,77.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,77.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,77.14,100,EAPG,,case rate,100% FL Medicaid EAPG,77.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,77.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,79.46,103,EAPG,,case rate,103% FL Medicaid EAPG,77.14,79.46,
OCULAR AND PERIOCULAR MALIGNANCY,556,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,101.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.29,100,EAPG,,case rate,100% FL Medicaid EAPG,101.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,104.32,103,EAPG,,case rate,103% FL Medicaid EAPG,101.29,104.32,
OTHER EYE INFECTION DIAGNOSES,557,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,64.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,64.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,64.74,100,EAPG,,case rate,100% FL Medicaid EAPG,64.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,64.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,66.68,103,EAPG,,case rate,103% FL Medicaid EAPG,64.74,66.68,
"MALFUNCTION, REACTION, OR COMPLICATION OF OCULAR DEVICE OR PROCEDURE",558,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,82.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,82.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,82.76,100,EAPG,,case rate,100% FL Medicaid EAPG,82.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,82.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.24,103,EAPG,,case rate,103% FL Medicaid EAPG,82.76,85.24,
"EAR, NOSE, MOUTH, THROAT, CRANIAL AND FACIAL MALIGNANCIES",560,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,104.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,104.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,104.68,100,EAPG,,case rate,100% FL Medicaid EAPG,104.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,104.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,107.82,103,EAPG,,case rate,103% FL Medicaid EAPG,104.68,107.82,
VERTIGO AND OTHER LABYRINTH DISORDERS,561,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,143.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,143.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,143.33,100,EAPG,,case rate,100% FL Medicaid EAPG,143.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,143.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,147.63,103,EAPG,,case rate,103% FL Medicaid EAPG,143.33,147.63,
INFECTIONS OF UPPER RESPIRATORY TRACT AND OTITIS MEDIA,562,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,115.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.09,100,EAPG,,case rate,100% FL Medicaid EAPG,115.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,118.54,103,EAPG,,case rate,103% FL Medicaid EAPG,115.09,118.54,
DENTAL AND ORAL DIAGNOSES AND INJURIES,563,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,86.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.39,100,EAPG,,case rate,100% FL Medicaid EAPG,86.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.98,103,EAPG,,case rate,103% FL Medicaid EAPG,86.39,88.98,
"OTHER EAR, NOSE, MOUTH, THROAT AND CRANIOFACIAL DIAGNOSES",564,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,99.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.37,100,EAPG,,case rate,100% FL Medicaid EAPG,99.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,102.36,103,EAPG,,case rate,103% FL Medicaid EAPG,99.37,102.36,
"MALFUNCTION, REACTION, OR COMPLICATION OF OTOLARYNGOLOGIC DEVICE OR PROCEDURE",566,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,95.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,95.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,95.2,100,EAPG,,case rate,100% FL Medicaid EAPG,95.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,95.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.06,103,EAPG,,case rate,103% FL Medicaid EAPG,95.2,98.06,
CYSTIC FIBROSIS - PULMONARY DISEASE,570,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,185.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,185.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,185.1,100,EAPG,,case rate,100% FL Medicaid EAPG,185.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,185.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,190.65,103,EAPG,,case rate,103% FL Medicaid EAPG,185.1,190.65,
RESPIRATORY MALIGNANCY,571,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,96.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,96.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,96.41,100,EAPG,,case rate,100% FL Medicaid EAPG,96.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,96.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.3,103,EAPG,,case rate,103% FL Medicaid EAPG,96.41,99.3,
BRONCHIOLITIS AND RSV PNEUMONIA,572,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,247.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,247.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,247.5,100,EAPG,,case rate,100% FL Medicaid EAPG,247.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,247.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,254.93,103,EAPG,,case rate,103% FL Medicaid EAPG,247.5,254.93,
CHRONIC OBSTRUCTIVE PULMONARY DISEASE,574,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,166.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.81,100,EAPG,,case rate,100% FL Medicaid EAPG,166.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,171.81,103,EAPG,,case rate,103% FL Medicaid EAPG,166.81,171.81,
ASTHMA,575,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,135.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,135.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,135.02,100,EAPG,,case rate,100% FL Medicaid EAPG,135.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,135.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,139.07,103,EAPG,,case rate,103% FL Medicaid EAPG,135.02,139.07,
OTHER RESPIRATORY SYSTEM DIAGNOSES,576,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,125.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,125.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,125.35,100,EAPG,,case rate,100% FL Medicaid EAPG,125.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,125.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,129.11,103,EAPG,,case rate,103% FL Medicaid EAPG,125.35,129.11,
STATUS ASTHMATICUS,579,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,218.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,218.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,218.29,100,EAPG,,case rate,100% FL Medicaid EAPG,218.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,218.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,224.84,103,EAPG,,case rate,103% FL Medicaid EAPG,218.29,224.84,
MAJOR CHEST AND RESPIRATORY TRAUMA,580,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,261.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,261.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,261.31,100,EAPG,,case rate,100% FL Medicaid EAPG,261.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,261.31,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,269.15,103,EAPG,,case rate,103% FL Medicaid EAPG,261.31,269.15,
PULMONARY INFECTION DIAGNOSES INCLUDING PNEUMONIA,581,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,203.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,203.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,203.94,100,EAPG,,case rate,100% FL Medicaid EAPG,203.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,203.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,210.05,103,EAPG,,case rate,103% FL Medicaid EAPG,203.94,210.05,
INTERSTITIAL AND ALVEOLAR LUNG DIAGNOSES,582,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,128.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,128.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,128.12,100,EAPG,,case rate,100% FL Medicaid EAPG,128.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,128.12,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,131.96,103,EAPG,,case rate,103% FL Medicaid EAPG,128.12,131.96,
"MALFUNCTION, REACTION, OR COMPLICATION OF PULMONARY DEVICE OR PROCEDURE",583,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,200.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,200.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,200.86,100,EAPG,,case rate,100% FL Medicaid EAPG,200.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,200.86,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,206.88,103,EAPG,,case rate,103% FL Medicaid EAPG,200.86,206.88,
ACUTE BRONCHITIS,584,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,165.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,165.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,165.36,100,EAPG,,case rate,100% FL Medicaid EAPG,165.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,165.36,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,170.33,103,EAPG,,case rate,103% FL Medicaid EAPG,165.36,170.33,
"AFTERCARE, OPEN WOUNDS AND OTHER TRAUMATIC INJURIES",585,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,75.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,75.78,100,EAPG,,case rate,100% FL Medicaid EAPG,75.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,75.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,78.05,103,EAPG,,case rate,103% FL Medicaid EAPG,75.78,78.05,
PULMONARY EMBOLISM,586,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,129.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,129.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,129.56,100,EAPG,,case rate,100% FL Medicaid EAPG,129.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,129.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,133.45,103,EAPG,,case rate,103% FL Medicaid EAPG,129.56,133.45,
RESPIRATORY FAILURE,587,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,305.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,305.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,305.81,100,EAPG,,case rate,100% FL Medicaid EAPG,305.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,305.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,314.98,103,EAPG,,case rate,103% FL Medicaid EAPG,305.81,314.98,
"MALFUNCTION, REACTION, OR COMPLICATION OF CARDIOVASCULAR DEVICE OR PROC",589,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,159.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,159.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,159.9,100,EAPG,,case rate,100% FL Medicaid EAPG,159.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,159.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,164.7,103,EAPG,,case rate,103% FL Medicaid EAPG,159.9,164.7,
ACUTE MYOCARDIAL INFARCTION,591,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,309.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,309.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,309.94,100,EAPG,,case rate,100% FL Medicaid EAPG,309.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,309.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,319.24,103,EAPG,,case rate,103% FL Medicaid EAPG,309.94,319.24,
OTHER CARDIOVASCULAR SYSTEM DIAGNOSES,592,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,122.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,122.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,122.35,100,EAPG,,case rate,100% FL Medicaid EAPG,122.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,122.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.02,103,EAPG,,case rate,103% FL Medicaid EAPG,122.35,126.02,
HEART FAILURE,594,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,129.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,129.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,129.76,100,EAPG,,case rate,100% FL Medicaid EAPG,129.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,129.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,133.65,103,EAPG,,case rate,103% FL Medicaid EAPG,129.76,133.65,
CARDIAC ARREST OR OTHER CAUSES OF MORTALITY,595,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,116.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,116.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,116.85,100,EAPG,,case rate,100% FL Medicaid EAPG,116.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,116.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,120.35,103,EAPG,,case rate,103% FL Medicaid EAPG,116.85,120.35,
PERIPHERAL AND OTHER VASCULAR DIAGNOSES,596,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,94.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,94.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,94.58,100,EAPG,,case rate,100% FL Medicaid EAPG,94.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,94.58,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,97.41,103,EAPG,,case rate,103% FL Medicaid EAPG,94.58,97.41,
PHLEBITIS,597,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,166.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.3,100,EAPG,,case rate,100% FL Medicaid EAPG,166.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,171.29,103,EAPG,,case rate,103% FL Medicaid EAPG,166.3,171.29,
ANGINA PECTORIS AND CORONARY ATHEROSCLEROSIS,598,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,85.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.61,100,EAPG,,case rate,100% FL Medicaid EAPG,85.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.18,103,EAPG,,case rate,103% FL Medicaid EAPG,85.61,88.18,
HYPERTENSION,599,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,89.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,89.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,89.47,100,EAPG,,case rate,100% FL Medicaid EAPG,89.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,89.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,92.15,103,EAPG,,case rate,103% FL Medicaid EAPG,89.47,92.15,
CARDIAC STRUCTURAL AND VALVULAR DIAGNOSES,600,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,81.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,81.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,81.59,100,EAPG,,case rate,100% FL Medicaid EAPG,81.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,81.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.04,103,EAPG,,case rate,103% FL Medicaid EAPG,81.59,84.04,
CARDIAC ARRHYTHMIA AND CONDUCTION DIAGNOSES,601,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,126.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.25,100,EAPG,,case rate,100% FL Medicaid EAPG,126.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,130.03,103,EAPG,,case rate,103% FL Medicaid EAPG,126.25,130.03,
ATRIAL FIBRILLATION,602,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,98.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.05,100,EAPG,,case rate,100% FL Medicaid EAPG,98.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,100.99,103,EAPG,,case rate,103% FL Medicaid EAPG,98.05,100.99,
CHEST PAIN,604,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,266.65,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,266.65,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,266.65,100,EAPG,,case rate,100% FL Medicaid EAPG,266.65,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,266.65,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,274.65,103,EAPG,,case rate,103% FL Medicaid EAPG,266.65,274.65,
SYNCOPE AND COLLAPSE,605,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,203.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,203.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,203.23,100,EAPG,,case rate,100% FL Medicaid EAPG,203.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,203.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,209.33,103,EAPG,,case rate,103% FL Medicaid EAPG,203.23,209.33,
CARDIOMYOPATHY DIAGNOSES,607,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,79.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,79.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,79.68,100,EAPG,,case rate,100% FL Medicaid EAPG,79.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,79.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,82.07,103,EAPG,,case rate,103% FL Medicaid EAPG,79.68,82.07,
ACUTE AND SUBACUTE ENDOCARDITIS,608,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,90.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,90.64,100,EAPG,,case rate,100% FL Medicaid EAPG,90.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,90.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,93.36,103,EAPG,,case rate,103% FL Medicaid EAPG,90.64,93.36,
CONTUSIONS TO EXTERNAL ORGANS OTHER THAN HEAD TRAUMA,610,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,164.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,164.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,164.55,100,EAPG,,case rate,100% FL Medicaid EAPG,164.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,164.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,169.48,103,EAPG,,case rate,103% FL Medicaid EAPG,164.55,169.48,
DIVERTICULITIS AND DIVERTICULOSIS,616,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,136.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,136.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,136.5,100,EAPG,,case rate,100% FL Medicaid EAPG,136.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,136.5,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,140.6,103,EAPG,,case rate,103% FL Medicaid EAPG,136.5,140.6,
GASTROINTESTINAL HEMORRHAGE AND RELATED POSTPROCEDURAL HEMORRHAGE DIAGNOSES,617,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,203.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,203.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,203.39,100,EAPG,,case rate,100% FL Medicaid EAPG,203.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,203.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,209.49,103,EAPG,,case rate,103% FL Medicaid EAPG,203.39,209.49,
INTESTINAL OBSTRUCTION DIAGNOSES,618,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,199.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,199.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,199.14,100,EAPG,,case rate,100% FL Medicaid EAPG,199.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,199.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,205.11,103,EAPG,,case rate,103% FL Medicaid EAPG,199.14,205.11,
GASTROINTESTINAL AND PERITONEAL INFECTION DIAGNOSES,619,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,158.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,158.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,158.93,100,EAPG,,case rate,100% FL Medicaid EAPG,158.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,158.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,163.7,103,EAPG,,case rate,103% FL Medicaid EAPG,158.93,163.7,
DIGESTIVE MALIGNANCY,620,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,114.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,114.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,114.62,100,EAPG,,case rate,100% FL Medicaid EAPG,114.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,114.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,118.06,103,EAPG,,case rate,103% FL Medicaid EAPG,114.62,118.06,
PEPTIC ULCER AND GASTRITIS,621,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,196.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,196.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,196.8,100,EAPG,,case rate,100% FL Medicaid EAPG,196.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,196.8,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,202.7,103,EAPG,,case rate,103% FL Medicaid EAPG,196.8,202.7,
ESOPHAGITIS AND OTHER ESOPHAGEAL DIAGNOSES,623,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,105.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,105.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,105.42,100,EAPG,,case rate,100% FL Medicaid EAPG,105.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,105.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,108.58,103,EAPG,,case rate,103% FL Medicaid EAPG,105.42,108.58,
OTHER GASTROINTESTINAL SYSTEM DIAGNOSES,624,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,120.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,120.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,120.08,100,EAPG,,case rate,100% FL Medicaid EAPG,120.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,120.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,123.69,103,EAPG,,case rate,103% FL Medicaid EAPG,120.08,123.69,
INFLAMMATORY BOWEL DISEASE,626,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,85.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.3,100,EAPG,,case rate,100% FL Medicaid EAPG,85.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.3,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.85,103,EAPG,,case rate,103% FL Medicaid EAPG,85.3,87.85,
"NON-BACTERIAL GASTROENTERITIS, NAUSEA AND VOMITING",627,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,136.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,136.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,136.66,100,EAPG,,case rate,100% FL Medicaid EAPG,136.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,136.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,140.76,103,EAPG,,case rate,103% FL Medicaid EAPG,136.66,140.76,
ABDOMINAL PAIN,628,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,156.51,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,156.51,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,156.51,100,EAPG,,case rate,100% FL Medicaid EAPG,156.51,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,156.51,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,161.21,103,EAPG,,case rate,103% FL Medicaid EAPG,156.51,161.21,
"MALFUNCTION, REACTION AND COMPLICATION OF GI DEVICE OR PROCEDURE",629,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,217,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,217,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,217,100,EAPG,,case rate,100% FL Medicaid EAPG,217,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,217,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,223.51,103,EAPG,,case rate,103% FL Medicaid EAPG,217,223.51,
CONSTIPATION,630,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,126.32,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.32,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.32,100,EAPG,,case rate,100% FL Medicaid EAPG,126.32,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.32,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,130.11,103,EAPG,,case rate,103% FL Medicaid EAPG,126.32,130.11,
HERNIA,631,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,98.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.4,100,EAPG,,case rate,100% FL Medicaid EAPG,98.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.35,103,EAPG,,case rate,103% FL Medicaid EAPG,98.4,101.35,
IRRITABLE BOWEL SYNDROME,632,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,73.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,73.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,73.09,100,EAPG,,case rate,100% FL Medicaid EAPG,73.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,73.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,75.28,103,EAPG,,case rate,103% FL Medicaid EAPG,73.09,75.28,
ALCOHOLIC LIVER DISEASE,633,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,117.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,117.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,117.59,100,EAPG,,case rate,100% FL Medicaid EAPG,117.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,117.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,121.12,103,EAPG,,case rate,103% FL Medicaid EAPG,117.59,121.12,
MALIGNANCY OF HEPATOBILIARY SYSTEM AND PANCREAS,634,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,135.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,135.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,135.37,100,EAPG,,case rate,100% FL Medicaid EAPG,135.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,135.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,139.43,103,EAPG,,case rate,103% FL Medicaid EAPG,135.37,139.43,
PANCREAS DIAGNOSES EXCEPT MALIGNANCY,635,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,142.67,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,142.67,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,142.67,100,EAPG,,case rate,100% FL Medicaid EAPG,142.67,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,142.67,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,146.95,103,EAPG,,case rate,103% FL Medicaid EAPG,142.67,146.95,
HEPATITIS WITHOUT COMA,636,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,110.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,110.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,110.02,100,EAPG,,case rate,100% FL Medicaid EAPG,110.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,110.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,113.32,103,EAPG,,case rate,103% FL Medicaid EAPG,110.02,113.32,
GALLBLADDER AND BILIARY TRACT DIAGNOSES,637,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,137.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,137.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,137.28,100,EAPG,,case rate,100% FL Medicaid EAPG,137.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,137.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,141.4,103,EAPG,,case rate,103% FL Medicaid EAPG,137.28,141.4,
CHOLECYSTITIS,638,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,189.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,189.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,189.47,100,EAPG,,case rate,100% FL Medicaid EAPG,189.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,189.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,195.15,103,EAPG,,case rate,103% FL Medicaid EAPG,189.47,195.15,
OTHER HEPATOBILIARY SYSTEM DIAGNOSES,639,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,119.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,119.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,119.23,100,EAPG,,case rate,100% FL Medicaid EAPG,119.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,119.23,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,122.8,103,EAPG,,case rate,103% FL Medicaid EAPG,119.23,122.8,
HEPATIC COMA AND MAJOR ACUTE LIVER DIAGNOSES,641,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,107.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,107.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,107.88,100,EAPG,,case rate,100% FL Medicaid EAPG,107.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,107.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,111.11,103,EAPG,,case rate,103% FL Medicaid EAPG,107.88,111.11,
GASTROINTESTINAL VASCULAR INSUFFICIENCY,642,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,139.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,139.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,139.7,100,EAPG,,case rate,100% FL Medicaid EAPG,139.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,139.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,143.89,103,EAPG,,case rate,103% FL Medicaid EAPG,139.7,143.89,
"FRACTURES, DISLOCATIONS, OTHER INJURIES - UPPER EXTREMITY INCLUDING SHOULDER",647,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,181.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,181.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,181.16,100,EAPG,,case rate,100% FL Medicaid EAPG,181.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,181.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,186.59,103,EAPG,,case rate,103% FL Medicaid EAPG,181.16,186.59,
"FRACTURES, DISLOCATIONS AND SPRAINS OF THE SKULL, CRANIUM AND FACE",648,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,209.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,209.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,209.28,100,EAPG,,case rate,100% FL Medicaid EAPG,209.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,209.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,215.56,103,EAPG,,case rate,103% FL Medicaid EAPG,209.28,215.56,
OTHER PATHOLOGICAL FRACTURES W/O MUSCULOSKELETAL MALIGNANCY,649,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,181.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,181.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,181.16,100,EAPG,,case rate,100% FL Medicaid EAPG,181.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,181.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,186.59,103,EAPG,,case rate,103% FL Medicaid EAPG,181.16,186.59,
"FRACTURES, DISLOCATIONS, OTHER INJURIES - LOWER EXTREMITY INCLUDING FEMUR",650,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,180.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,180.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,180.61,100,EAPG,,case rate,100% FL Medicaid EAPG,180.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,180.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,186.03,103,EAPG,,case rate,103% FL Medicaid EAPG,180.61,186.03,
"FRACTURES, DISLOCATIONS, SPRAINS AND OTHER INJURIES OF THE PELVIS AND HIP",651,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,228.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,228.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,228.82,100,EAPG,,case rate,100% FL Medicaid EAPG,228.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,228.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,235.68,103,EAPG,,case rate,103% FL Medicaid EAPG,228.82,235.68,
OTHER INJURIES AND DISORDERS OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE,652,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,91.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.57,100,EAPG,,case rate,100% FL Medicaid EAPG,91.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,94.32,103,EAPG,,case rate,103% FL Medicaid EAPG,91.57,94.32,
MUSCULOSKELETAL MALIGNANCY AND PATHOLOGICAL FX DUE TO MALIGNANCY,653,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,121.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,121.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,121.41,100,EAPG,,case rate,100% FL Medicaid EAPG,121.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,121.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,125.05,103,EAPG,,case rate,103% FL Medicaid EAPG,121.41,125.05,
"OSTEOMYELITIS, SEPTIC ARTHRITIS AND OTHER MUSCULOSKELETAL INFECTIONS",654,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,99.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.26,100,EAPG,,case rate,100% FL Medicaid EAPG,99.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,102.24,103,EAPG,,case rate,103% FL Medicaid EAPG,99.26,102.24,
CONNECTIVE TISSUE DIAGNOSES,655,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,81.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,81.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,81.71,100,EAPG,,case rate,100% FL Medicaid EAPG,81.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,81.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.16,103,EAPG,,case rate,103% FL Medicaid EAPG,81.71,84.16,
"FRACTURES, DISLOCATIONS, OTHER INJURIES OF THE NECK, UPPER BACK AND CHEST",656,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,203.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,203.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,203.55,100,EAPG,,case rate,100% FL Medicaid EAPG,203.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,203.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,209.65,103,EAPG,,case rate,103% FL Medicaid EAPG,203.55,209.65,
"FRACTURES, DISLOCATIONS, SPRAINS AND OTHER INJURIES OF THE LOWER BACK",657,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,114.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,114.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,114.19,100,EAPG,,case rate,100% FL Medicaid EAPG,114.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,114.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,117.62,103,EAPG,,case rate,103% FL Medicaid EAPG,114.19,117.62,
SCIATICA AND LOW BACK PAIN,658,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,103.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,103.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,103.08,100,EAPG,,case rate,100% FL Medicaid EAPG,103.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,103.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,106.17,103,EAPG,,case rate,103% FL Medicaid EAPG,103.08,106.17,
"MALFUNCTION, REACTION, COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE",659,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,127.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,127.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,127.1,100,EAPG,,case rate,100% FL Medicaid EAPG,127.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,127.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,130.92,103,EAPG,,case rate,103% FL Medicaid EAPG,127.1,130.92,
OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES,660,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,110.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,110.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,110.29,100,EAPG,,case rate,100% FL Medicaid EAPG,110.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,110.29,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,113.6,103,EAPG,,case rate,103% FL Medicaid EAPG,110.29,113.6,
OSTEOPOROSIS,662,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,84.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.01,100,EAPG,,case rate,100% FL Medicaid EAPG,84.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.53,103,EAPG,,case rate,103% FL Medicaid EAPG,84.01,86.53,
PAIN RELATED DIAGNOSES,663,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,88.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.96,100,EAPG,,case rate,100% FL Medicaid EAPG,88.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.96,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.63,103,EAPG,,case rate,103% FL Medicaid EAPG,88.96,91.63,
NON-PRESSURE CHRONIC SKIN ULCERS,670,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,83.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.7,100,EAPG,,case rate,100% FL Medicaid EAPG,83.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.7,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.21,103,EAPG,,case rate,103% FL Medicaid EAPG,83.7,86.21,
MAJOR SKIN DIAGNOSES,671,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,79.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,79.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,79.41,100,EAPG,,case rate,100% FL Medicaid EAPG,79.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,79.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,81.79,103,EAPG,,case rate,103% FL Medicaid EAPG,79.41,81.79,
MALIGNANT BREAST DIAGNOSES,672,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,87.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.25,100,EAPG,,case rate,100% FL Medicaid EAPG,87.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,89.86,103,EAPG,,case rate,103% FL Medicaid EAPG,87.25,89.86,
CELLULITIS AND OTHER BACTERIAL SKIN INFECTIONS,673,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,128,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,128,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,128,100,EAPG,,case rate,100% FL Medicaid EAPG,128,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,128,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,131.84,103,EAPG,,case rate,103% FL Medicaid EAPG,128,131.84,
"OPEN WOUNDS, PUNCTURES AND OTHER OPEN TRAUMATIC INJURIES",674,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,109.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,109.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,109.94,100,EAPG,,case rate,100% FL Medicaid EAPG,109.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,109.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,113.24,103,EAPG,,case rate,103% FL Medicaid EAPG,109.94,113.24,
"OTHER SKIN, SUBCUTANEOUS TISSUE AND BREAST DIAGNOSES",675,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,70.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,70.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,70.4,100,EAPG,,case rate,100% FL Medicaid EAPG,70.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,70.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,72.51,103,EAPG,,case rate,103% FL Medicaid EAPG,70.4,72.51,
PRESSURE ULCERS,676,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,86.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.89,100,EAPG,,case rate,100% FL Medicaid EAPG,86.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,89.5,103,EAPG,,case rate,103% FL Medicaid EAPG,86.89,89.5,
"MALNUTRITION, FAILURE TO THRIVE AND OTHER NUTRITIONAL DIAGNOSES",690,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,108.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,108.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,108.73,100,EAPG,,case rate,100% FL Medicaid EAPG,108.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,108.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,112,103,EAPG,,case rate,103% FL Medicaid EAPG,108.73,112,
INBORN ERRORS OF METABOLISM,691,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,76.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,76.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,76.52,100,EAPG,,case rate,100% FL Medicaid EAPG,76.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,76.52,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,78.82,103,EAPG,,case rate,103% FL Medicaid EAPG,76.52,78.82,
OTHER ENDOCRINE SYSTEM DIAGNOSES,692,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,91.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.61,100,EAPG,,case rate,100% FL Medicaid EAPG,91.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,94.36,103,EAPG,,case rate,103% FL Medicaid EAPG,91.61,94.36,
ELECTROLYTE DISORDERS,694,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,162.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,162.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,162.28,100,EAPG,,case rate,100% FL Medicaid EAPG,162.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,162.28,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,167.15,103,EAPG,,case rate,103% FL Medicaid EAPG,162.28,167.15,
OBESITY,695,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,69.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,69.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,69.54,100,EAPG,,case rate,100% FL Medicaid EAPG,69.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,69.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,71.62,103,EAPG,,case rate,103% FL Medicaid EAPG,69.54,71.62,
THYROID AND PARATHYROID DIAGNOSES,696,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,83.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.89,100,EAPG,,case rate,100% FL Medicaid EAPG,83.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.41,103,EAPG,,case rate,103% FL Medicaid EAPG,83.89,86.41,
DIABETES WITH OPHTHALMIC MANIFESTATIONS,710,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,117.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,117.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,117.55,100,EAPG,,case rate,100% FL Medicaid EAPG,117.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,117.55,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,121.08,103,EAPG,,case rate,103% FL Medicaid EAPG,117.55,121.08,
DIABETES WITH OTHER MANIFESTATIONS AND COMPLICATIONS,711,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,104.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,104.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,104.13,100,EAPG,,case rate,100% FL Medicaid EAPG,104.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,104.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,107.26,103,EAPG,,case rate,103% FL Medicaid EAPG,104.13,107.26,
DIABETES WITH NEUROLOGIC MANIFESTATIONS,712,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,81.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,81.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,81.47,100,EAPG,,case rate,100% FL Medicaid EAPG,81.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,81.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.92,103,EAPG,,case rate,103% FL Medicaid EAPG,81.47,83.92,
DIABETES WITHOUT COMPLICATIONS,713,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,75.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,75.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,75.78,100,EAPG,,case rate,100% FL Medicaid EAPG,75.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,75.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,78.05,103,EAPG,,case rate,103% FL Medicaid EAPG,75.78,78.05,
DIABETES WITH RENAL MANIFESTATIONS,714,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,84.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.05,100,EAPG,,case rate,100% FL Medicaid EAPG,84.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.57,103,EAPG,,case rate,103% FL Medicaid EAPG,84.05,86.57,
DIABETES WITH VASCULAR COMPLICATIONS INCLUDING FOOT AND OTHER SKIN ULCERS,715,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,84.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.44,100,EAPG,,case rate,100% FL Medicaid EAPG,84.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.97,103,EAPG,,case rate,103% FL Medicaid EAPG,84.44,86.97,
CHRONIC KIDNEY DISEASE,720,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,92.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,92.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,92.24,100,EAPG,,case rate,100% FL Medicaid EAPG,92.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,92.24,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,95,103,EAPG,,case rate,103% FL Medicaid EAPG,92.24,95,
KIDNEY AND URINARY TRACT MALIGNANCY,721,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,87.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.95,100,EAPG,,case rate,100% FL Medicaid EAPG,87.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,90.59,103,EAPG,,case rate,103% FL Medicaid EAPG,87.95,90.59,
NEPHRITIS AND NEPHROSIS,722,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,102.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,102.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,102.38,100,EAPG,,case rate,100% FL Medicaid EAPG,102.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,102.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,105.45,103,EAPG,,case rate,103% FL Medicaid EAPG,102.38,105.45,
COMPLEX KIDNEY AND URINARY TRACT INFECTIONS,723,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,166.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.22,100,EAPG,,case rate,100% FL Medicaid EAPG,166.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,171.21,103,EAPG,,case rate,103% FL Medicaid EAPG,166.22,171.21,
URINARY STONES AND ACQUIRED UPPER URINARY TRACT OBSTRUCTION,724,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,99.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.49,100,EAPG,,case rate,100% FL Medicaid EAPG,99.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,102.48,103,EAPG,,case rate,103% FL Medicaid EAPG,99.49,102.48,
"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",725,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,163.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,163.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,163.84,100,EAPG,,case rate,100% FL Medicaid EAPG,163.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,163.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,168.76,103,EAPG,,case rate,103% FL Medicaid EAPG,163.84,168.76,
"OTHER KIDNEY AND URINARY TRACT DIAGNOSES, SIGNS AND SYMPTOMS",726,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,104.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,104.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,104.13,100,EAPG,,case rate,100% FL Medicaid EAPG,104.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,104.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,107.26,103,EAPG,,case rate,103% FL Medicaid EAPG,104.13,107.26,
ACUTE LOWER URINARY TRACT INFECTIONS,727,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,156.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,156.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,156.16,100,EAPG,,case rate,100% FL Medicaid EAPG,156.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,156.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,160.84,103,EAPG,,case rate,103% FL Medicaid EAPG,156.16,160.84,
ACUTE KIDNEY INJURY,729,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,221.21,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,221.21,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,221.21,100,EAPG,,case rate,100% FL Medicaid EAPG,221.21,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,221.21,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,227.85,103,EAPG,,case rate,103% FL Medicaid EAPG,221.21,227.85,
MALE REPRODUCTIVE SYSTEM MALIGNANCY,740,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,91.65,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.65,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.65,100,EAPG,,case rate,100% FL Medicaid EAPG,91.65,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.65,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,94.4,103,EAPG,,case rate,103% FL Medicaid EAPG,91.65,94.4,
OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES,741,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,100.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,100.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,100.39,100,EAPG,,case rate,100% FL Medicaid EAPG,100.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,100.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,103.4,103,EAPG,,case rate,103% FL Medicaid EAPG,100.39,103.4,
PROSTATITIS,743,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,88.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.26,100,EAPG,,case rate,100% FL Medicaid EAPG,88.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,90.91,103,EAPG,,case rate,103% FL Medicaid EAPG,88.26,90.91,
MALE REPRODUCTIVE SYSTEM INFECTIONS,744,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,91.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.93,100,EAPG,,case rate,100% FL Medicaid EAPG,91.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,94.68,103,EAPG,,case rate,103% FL Medicaid EAPG,91.93,94.68,
FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,750,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,99.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.88,100,EAPG,,case rate,100% FL Medicaid EAPG,99.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.88,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,102.88,103,EAPG,,case rate,103% FL Medicaid EAPG,99.88,102.88,
FEMALE REPRODUCTIVE SYSTEM INFECTIONS,751,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,115.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.01,100,EAPG,,case rate,100% FL Medicaid EAPG,115.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,118.46,103,EAPG,,case rate,103% FL Medicaid EAPG,115.01,118.46,
OTHER FEMALE REPRODUCTIVE SYSTEM AND MENSTRUAL DIAGNOSES,752,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,88.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.81,100,EAPG,,case rate,100% FL Medicaid EAPG,88.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.81,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.47,103,EAPG,,case rate,103% FL Medicaid EAPG,88.81,91.47,
LABOR AND DELIVERY RELATED DIAGNOSES,760,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,157.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,157.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,157.56,100,EAPG,,case rate,100% FL Medicaid EAPG,157.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,157.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,162.29,103,EAPG,,case rate,103% FL Medicaid EAPG,157.56,162.29,
POSTPARTUM AND POST ABORTION DIAGNOSES,761,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,143.17,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,143.17,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,143.17,100,EAPG,,case rate,100% FL Medicaid EAPG,143.17,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,143.17,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,147.47,103,EAPG,,case rate,103% FL Medicaid EAPG,143.17,147.47,
PRETERM LABOR DIAGNOSES,762,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,252.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,252.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,252.22,100,EAPG,,case rate,100% FL Medicaid EAPG,252.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,252.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,259.79,103,EAPG,,case rate,103% FL Medicaid EAPG,252.22,259.79,
ABORTION RELATED DIAGNOSES,763,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,231.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,231.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,231.39,100,EAPG,,case rate,100% FL Medicaid EAPG,231.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,231.39,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,238.33,103,EAPG,,case rate,103% FL Medicaid EAPG,231.39,238.33,
FALSE LABOR,764,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,139.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,139.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,139.9,100,EAPG,,case rate,100% FL Medicaid EAPG,139.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,139.9,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,144.09,103,EAPG,,case rate,103% FL Medicaid EAPG,139.9,144.09,
OTHER ANTEPARTUM COMPLICATION DIAGNOSES,765,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,173.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,173.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,173.4,100,EAPG,,case rate,100% FL Medicaid EAPG,173.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,173.4,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,178.6,103,EAPG,,case rate,103% FL Medicaid EAPG,173.4,178.6,
ROUTINE PRENATAL CARE,766,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,108.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,108.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,108.38,100,EAPG,,case rate,100% FL Medicaid EAPG,108.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,108.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,111.64,103,EAPG,,case rate,103% FL Medicaid EAPG,108.38,111.64,
COMPLICATIONS OF TREATMENT AFFECTING PREGNANCY,767,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,263.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,263.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,263.41,100,EAPG,,case rate,100% FL Medicaid EAPG,263.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,263.41,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,271.32,103,EAPG,,case rate,103% FL Medicaid EAPG,263.41,271.32,
ANTEPARTUM ENCOUNTERS FOR NON-ROUTINE AND ABNORMAL FINDINGS,768,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,160.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,160.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,160.22,100,EAPG,,case rate,100% FL Medicaid EAPG,160.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,160.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,165.02,103,EAPG,,case rate,103% FL Medicaid EAPG,160.22,165.02,
NORMAL NEONATE,770,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,90.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,90.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,90.79,100,EAPG,,case rate,100% FL Medicaid EAPG,90.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,90.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,93.52,103,EAPG,,case rate,103% FL Medicaid EAPG,90.79,93.52,
NEONATAL DIAGNOSES,771,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,154.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,154.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,154.48,100,EAPG,,case rate,100% FL Medicaid EAPG,154.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,154.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,159.12,103,EAPG,,case rate,103% FL Medicaid EAPG,154.48,159.12,
SUPERFICIAL INJURY TO SKIN AND SUBCUTANEOUS TISSUE,777,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,126.99,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.99,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.99,100,EAPG,,case rate,100% FL Medicaid EAPG,126.99,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.99,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,130.8,103,EAPG,,case rate,103% FL Medicaid EAPG,126.99,130.8,
OTHER HEMATOLOGICAL DIAGNOSES,780,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,128,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,128,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,128,100,EAPG,,case rate,100% FL Medicaid EAPG,128,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,128,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,131.84,103,EAPG,,case rate,103% FL Medicaid EAPG,128,131.84,
COAGULATION AND PLATELET DISORDERS AND CONGENITAL FACTOR DEFICIENCIES,781,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,93.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,93.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,93.49,100,EAPG,,case rate,100% FL Medicaid EAPG,93.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,93.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,96.29,103,EAPG,,case rate,103% FL Medicaid EAPG,93.49,96.29,
SICKLE CELL ANEMIA CRISIS,783,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,195.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,195.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,195.71,100,EAPG,,case rate,100% FL Medicaid EAPG,195.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,195.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,201.58,103,EAPG,,case rate,103% FL Medicaid EAPG,195.71,201.58,
"ANEMIA, BLOOD AND BLOOD-FORMING ORGAN DISORDERS",785,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,115.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.33,100,EAPG,,case rate,100% FL Medicaid EAPG,115.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,118.79,103,EAPG,,case rate,103% FL Medicaid EAPG,115.33,118.79,
"AFTERCARE, BURNS, CORROSIONS, OTHER INJURIES RELATED TO THE SKIN AND SUB TIS",787,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,79.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,79.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,79.48,100,EAPG,,case rate,100% FL Medicaid EAPG,79.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,79.48,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,81.87,103,EAPG,,case rate,103% FL Medicaid EAPG,79.48,81.87,
ACUTE LEUKEMIA,800,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,173.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,173.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,173.05,100,EAPG,,case rate,100% FL Medicaid EAPG,173.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,173.05,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,178.24,103,EAPG,,case rate,103% FL Medicaid EAPG,173.05,178.24,
"LYMPHOMA, MYELOMA AND NON-ACUTE LEUKEMIA",801,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,124.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,124.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,124.49,100,EAPG,,case rate,100% FL Medicaid EAPG,124.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,124.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,128.23,103,EAPG,,case rate,103% FL Medicaid EAPG,124.49,128.23,
RADIOTHERAPY,802,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,92.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,92.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,92.08,100,EAPG,,case rate,100% FL Medicaid EAPG,92.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,92.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,94.84,103,EAPG,,case rate,103% FL Medicaid EAPG,92.08,94.84,
CHEMOTHERAPY,803,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,138.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,138.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,138.61,100,EAPG,,case rate,100% FL Medicaid EAPG,138.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,138.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,142.77,103,EAPG,,case rate,103% FL Medicaid EAPG,138.61,142.77,
LYMPHATIC AND OTHER MALIGNANCIES AND NEOPLASMS OF UNCERTAIN BEHAVIOR,804,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,111.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,111.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,111.46,100,EAPG,,case rate,100% FL Medicaid EAPG,111.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,111.46,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,114.81,103,EAPG,,case rate,103% FL Medicaid EAPG,111.46,114.81,
SEPTICEMIA AND DISSEMINATED INFECTIONS,805,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,444.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,444.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,444.57,100,EAPG,,case rate,100% FL Medicaid EAPG,444.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,444.57,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,457.91,103,EAPG,,case rate,103% FL Medicaid EAPG,444.57,457.91,
"INTRAOPERATIVE, POST-OPERATIVE OR POST-TRAUMATIC INFECTIONS AND COMPLICATIONS",806,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,139.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,139.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,139.94,100,EAPG,,case rate,100% FL Medicaid EAPG,139.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,139.94,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,144.13,103,EAPG,,case rate,103% FL Medicaid EAPG,139.94,144.13,
FEVER AND OTHER INFLAMMATORY CONDITIONS,807,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,223.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,223.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,223.98,100,EAPG,,case rate,100% FL Medicaid EAPG,223.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,223.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,230.7,103,EAPG,,case rate,103% FL Medicaid EAPG,223.98,230.7,
VIRAL ILLNESS,808,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,197.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,197.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,197.66,100,EAPG,,case rate,100% FL Medicaid EAPG,197.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,197.66,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,203.59,103,EAPG,,case rate,103% FL Medicaid EAPG,197.66,203.59,
OTHER INFECTIOUS AND PARASITIC DISEASES,809,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,101.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.68,100,EAPG,,case rate,100% FL Medicaid EAPG,101.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.68,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,104.73,103,EAPG,,case rate,103% FL Medicaid EAPG,101.68,104.73,
H. PYLORI INFECTION,810,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,80.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,80.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,80.19,100,EAPG,,case rate,100% FL Medicaid EAPG,80.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,80.19,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,82.59,103,EAPG,,case rate,103% FL Medicaid EAPG,80.19,82.59,
VIRAL MENINGITIS,812,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,161.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,161.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,161.27,100,EAPG,,case rate,100% FL Medicaid EAPG,161.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,161.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,166.11,103,EAPG,,case rate,103% FL Medicaid EAPG,161.27,166.11,
SCHIZOPHRENIA,820,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,141.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,141.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,141.26,100,EAPG,,case rate,100% FL Medicaid EAPG,141.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,141.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,145.5,103,EAPG,,case rate,103% FL Medicaid EAPG,141.26,145.5,
MAJOR DEPRESSIVE DIAGNOSES AND  OTHER OR UNSPECIFIED PSYCHOSES,821,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,95.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,95.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,95.2,100,EAPG,,case rate,100% FL Medicaid EAPG,95.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,95.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.06,103,EAPG,,case rate,103% FL Medicaid EAPG,95.2,98.06,
PERSONALITY AND IMPULSE CONTROL DIAGNOSES,822,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,148.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,148.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,148.79,100,EAPG,,case rate,100% FL Medicaid EAPG,148.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,148.79,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,153.25,103,EAPG,,case rate,103% FL Medicaid EAPG,148.79,153.25,
BIPOLAR DISORDERS,823,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,108.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,108.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,108.27,100,EAPG,,case rate,100% FL Medicaid EAPG,108.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,108.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,111.51,103,EAPG,,case rate,103% FL Medicaid EAPG,108.27,111.51,
DEPRESSION EXCEPT MAJOR DEPRESSIVE DIAGNOSES,824,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,122.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,122.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,122.89,100,EAPG,,case rate,100% FL Medicaid EAPG,122.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,122.89,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,126.58,103,EAPG,,case rate,103% FL Medicaid EAPG,122.89,126.58,
ADJUSTMENT DISORDERS AND NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,825,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,103.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,103.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,103.27,100,EAPG,,case rate,100% FL Medicaid EAPG,103.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,103.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,106.37,103,EAPG,,case rate,103% FL Medicaid EAPG,103.27,106.37,
ACUTE ANXIETY AND DELIRIUM STATES,826,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,136,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,136,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,136,100,EAPG,,case rate,100% FL Medicaid EAPG,136,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,136,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,140.08,103,EAPG,,case rate,103% FL Medicaid EAPG,136,140.08,
ORGANIC BEHAVIORAL HEALTH DISTURBANCES,827,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,93.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,93.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,93.76,100,EAPG,,case rate,100% FL Medicaid EAPG,93.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,93.76,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,96.57,103,EAPG,,case rate,103% FL Medicaid EAPG,93.76,96.57,
INTELLECTUAL DISABILITY,828,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,89.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,89.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,89.27,100,EAPG,,case rate,100% FL Medicaid EAPG,89.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,89.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.95,103,EAPG,,case rate,103% FL Medicaid EAPG,89.27,91.95,
CHILDHOOD BEHAVIORAL DIAGNOSES,829,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,95.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,95.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,95.98,100,EAPG,,case rate,100% FL Medicaid EAPG,95.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,95.98,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,98.86,103,EAPG,,case rate,103% FL Medicaid EAPG,95.98,98.86,
EATING DISORDERS,830,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,108.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,108.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,108.11,100,EAPG,,case rate,100% FL Medicaid EAPG,108.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,108.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,111.35,103,EAPG,,case rate,103% FL Medicaid EAPG,108.11,111.35,
OTHER BEHAVIORAL HEALTH DIAGNOSES,831,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,133.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,133.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,133.11,100,EAPG,,case rate,100% FL Medicaid EAPG,133.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,133.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,137.1,103,EAPG,,case rate,103% FL Medicaid EAPG,133.11,137.1,
INTENTIONAL SELF-HARM AND ATTEMPTED SUICIDE,832,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,332.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,332.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,332.37,100,EAPG,,case rate,100% FL Medicaid EAPG,332.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,332.37,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,342.34,103,EAPG,,case rate,103% FL Medicaid EAPG,332.37,342.34,
OPIOID ABUSE AND DEPENDENCE,840,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,97.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,97.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,97.42,100,EAPG,,case rate,100% FL Medicaid EAPG,97.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,97.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,100.35,103,EAPG,,case rate,103% FL Medicaid EAPG,97.42,100.35,
COCAINE ABUSE AND DEPENDENCE,841,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,187.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,187.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,187.71,100,EAPG,,case rate,100% FL Medicaid EAPG,187.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,187.71,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,193.34,103,EAPG,,case rate,103% FL Medicaid EAPG,187.71,193.34,
ALCOHOL ABUSE AND DEPENDENCE,842,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,180.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,180.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,180.54,100,EAPG,,case rate,100% FL Medicaid EAPG,180.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,180.54,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,185.95,103,EAPG,,case rate,103% FL Medicaid EAPG,180.54,185.95,
OTHER DRUG ABUSE AND DEPENDENCE,843,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,172.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,172.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,172.27,100,EAPG,,case rate,100% FL Medicaid EAPG,172.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,172.27,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,177.44,103,EAPG,,case rate,103% FL Medicaid EAPG,172.27,177.44,
ALLERGIC REACTIONS,850,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,170.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,170.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,170.59,100,EAPG,,case rate,100% FL Medicaid EAPG,170.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,170.59,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,175.71,103,EAPG,,case rate,103% FL Medicaid EAPG,170.59,175.71,
POISONING OR TOXIC EFFECTS OF MEDICINAL AGENTS,851,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,182.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,182.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,182.84,100,EAPG,,case rate,100% FL Medicaid EAPG,182.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,182.84,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,188.32,103,EAPG,,case rate,103% FL Medicaid EAPG,182.84,188.32,
OTHER COMPLICATIONS OF TREATMENT,852,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,117.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,117.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,117.47,100,EAPG,,case rate,100% FL Medicaid EAPG,117.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,117.47,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,121,103,EAPG,,case rate,103% FL Medicaid EAPG,117.47,121,
"OTHER INJURY, POISONING AND TOXIC EFFECT DIAGNOSES",853,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,109.75,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,109.75,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,109.75,100,EAPG,,case rate,100% FL Medicaid EAPG,109.75,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,109.75,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,113.04,103,EAPG,,case rate,103% FL Medicaid EAPG,109.75,113.04,
TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,854,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,133.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,133.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,133.93,100,EAPG,,case rate,100% FL Medicaid EAPG,133.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,133.93,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,137.95,103,EAPG,,case rate,103% FL Medicaid EAPG,133.93,137.95,
EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS,860,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,111.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,111.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,111.82,100,EAPG,,case rate,100% FL Medicaid EAPG,111.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,111.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.17,103,EAPG,,case rate,103% FL Medicaid EAPG,111.82,115.17,
PARTIAL THICKNESS BURNS,861,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,112.21,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,112.21,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,112.21,100,EAPG,,case rate,100% FL Medicaid EAPG,112.21,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,112.21,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.57,103,EAPG,,case rate,103% FL Medicaid EAPG,112.21,115.57,
ENCOUNTERS FOR CONTACT WITH HEALTH SERVICES,867,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,83.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.11,100,EAPG,,case rate,100% FL Medicaid EAPG,83.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.11,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.6,103,EAPG,,case rate,103% FL Medicaid EAPG,83.11,85.6,
"AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE INJURIES",869,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,84.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.09,100,EAPG,,case rate,100% FL Medicaid EAPG,84.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,84.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.61,103,EAPG,,case rate,103% FL Medicaid EAPG,84.09,86.61,
REHABILITATION,870,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,99.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.61,100,EAPG,,case rate,100% FL Medicaid EAPG,99.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.61,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,102.6,103,EAPG,,case rate,103% FL Medicaid EAPG,99.61,102.6,
"SIGNS, SYMPTOMS AND OTHER FACTORS INFLUENCING HEALTH STATUS",871,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,111.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,111.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,111.85,100,EAPG,,case rate,100% FL Medicaid EAPG,111.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,111.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.21,103,EAPG,,case rate,103% FL Medicaid EAPG,111.85,115.21,
OTHER AFTERCARE AND CONVALESCENCE,872,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,104.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,104.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,104.64,100,EAPG,,case rate,100% FL Medicaid EAPG,104.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,104.64,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,107.78,103,EAPG,,case rate,103% FL Medicaid EAPG,104.64,107.78,
NEONATAL AFTERCARE,873,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,63.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,63.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,63.22,100,EAPG,,case rate,100% FL Medicaid EAPG,63.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,63.22,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,65.12,103,EAPG,,case rate,103% FL Medicaid EAPG,63.22,65.12,
AFTERCARE FOR JOINT REPLACEMENT,874,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,80.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,80.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,80.62,100,EAPG,,case rate,100% FL Medicaid EAPG,80.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,80.62,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,83.03,103,EAPG,,case rate,103% FL Medicaid EAPG,80.62,83.03,
CONTRACEPTIVE MANAGEMENT,875,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,100.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,100.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,100.08,100,EAPG,,case rate,100% FL Medicaid EAPG,100.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,100.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,103.08,103,EAPG,,case rate,103% FL Medicaid EAPG,100.08,103.08,
ADULT PREVENTIVE MEDICINE,876,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,101.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.56,100,EAPG,,case rate,100% FL Medicaid EAPG,101.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.56,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,104.61,103,EAPG,,case rate,103% FL Medicaid EAPG,101.56,104.61,
CHILD PREVENTIVE MEDICINE,877,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,85.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.92,100,EAPG,,case rate,100% FL Medicaid EAPG,85.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.92,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,88.5,103,EAPG,,case rate,103% FL Medicaid EAPG,85.92,88.5,
GYNECOLOGIC PREVENTIVE MEDICINE,878,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,71.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,71.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,71.25,100,EAPG,,case rate,100% FL Medicaid EAPG,71.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,71.25,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,73.39,103,EAPG,,case rate,103% FL Medicaid EAPG,71.25,73.39,
PREVENTIVE OR SCREENING ENCOUNTER,879,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,94.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,94.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,94.73,100,EAPG,,case rate,100% FL Medicaid EAPG,94.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,94.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,97.58,103,EAPG,,case rate,103% FL Medicaid EAPG,94.73,97.58,
HIV INFECTION,880,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,147.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,147.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,147.35,100,EAPG,,case rate,100% FL Medicaid EAPG,147.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,147.35,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,151.77,103,EAPG,,case rate,103% FL Medicaid EAPG,147.35,151.77,
AIDS,881,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,149.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,149.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,149.26,100,EAPG,,case rate,100% FL Medicaid EAPG,149.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,149.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,153.73,103,EAPG,,case rate,103% FL Medicaid EAPG,149.26,153.73,
GENETIC COUNSELING,882,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,112.87,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,112.87,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,112.87,100,EAPG,,case rate,100% FL Medicaid EAPG,112.87,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,112.87,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,116.25,103,EAPG,,case rate,103% FL Medicaid EAPG,112.87,116.25,
ALTERATION IN CONSCIOUSNESS,883,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,259.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,259.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,259.2,100,EAPG,,case rate,100% FL Medicaid EAPG,259.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,259.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,266.98,103,EAPG,,case rate,103% FL Medicaid EAPG,259.2,266.98,
AUTOPSY AND POST-MORTEM EXAMINATION SERVICES,900,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,99.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.02,100,EAPG,,case rate,100% FL Medicaid EAPG,99.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,99.02,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,101.99,103,EAPG,,case rate,103% FL Medicaid EAPG,99.02,101.99,
LEVEL II ALLERGY TESTS,2016,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,24.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,24.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,24.49,100,EAPG,,case rate,100% FL Medicaid EAPG,24.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,24.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,25.23,103,EAPG,,case rate,103% FL Medicaid EAPG,24.49,25.23,
NONINVASIVE VENTILATION SUPPORT,2020,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,91.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.26,100,EAPG,,case rate,100% FL Medicaid EAPG,91.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,91.26,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,94,103,EAPG,,case rate,103% FL Medicaid EAPG,91.26,94,
MINOR MUSCULOSKELETAL PROCEDURES,2030,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,112.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,112.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,112.13,100,EAPG,,case rate,100% FL Medicaid EAPG,112.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,112.13,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,115.49,103,EAPG,,case rate,103% FL Medicaid EAPG,112.13,115.49,
LEVEL I DRUG SCREENING AND DEFINITIVE TESTS,2040,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7.33,100,EAPG,,case rate,100% FL Medicaid EAPG,7.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7.33,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7.55,103,EAPG,,case rate,103% FL Medicaid EAPG,7.33,7.55,
LEVEL II DRUG SCREENING AND DEFINITIVE TESTS,2041,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,36.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,36.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,36.78,100,EAPG,,case rate,100% FL Medicaid EAPG,36.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,36.78,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,37.88,103,EAPG,,case rate,103% FL Medicaid EAPG,36.78,37.88,
LEVEL III DRUG SCREENING AND DEFINITIVE TESTS,2042,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,85.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.14,100,EAPG,,case rate,100% FL Medicaid EAPG,85.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,85.14,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.69,103,EAPG,,case rate,103% FL Medicaid EAPG,85.14,87.69,
LEVEL III BLOOD AND TISSUE TYPING TESTS,2043,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,86.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.82,100,EAPG,,case rate,100% FL Medicaid EAPG,86.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,86.82,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,89.42,103,EAPG,,case rate,103% FL Medicaid EAPG,86.82,89.42,
"LEVEL IV COMPLEX LABORATORY, MOLECULAR PATHOLOGY AND GENETIC TESTS",2044,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,345.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,345.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,345.74,100,EAPG,,case rate,100% FL Medicaid EAPG,345.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,345.74,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,356.12,103,EAPG,,case rate,103% FL Medicaid EAPG,345.74,356.12,
ADVANCED MOLECULAR PATHOLOGY AND GENETIC TESTS,2045,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,1242.18,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1242.18,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1242.18,100,EAPG,,case rate,100% FL Medicaid EAPG,1242.18,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1242.18,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,1279.45,103,EAPG,,case rate,103% FL Medicaid EAPG,1242.18,1279.45,
CLASS I BLOOD PRODUCTS,2061,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,87.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.44,100,EAPG,,case rate,100% FL Medicaid EAPG,87.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,87.44,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,90.06,103,EAPG,,case rate,103% FL Medicaid EAPG,87.44,90.06,
CLASS II BLOOD PRODUCTS,2062,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,196.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,196.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,196.1,100,EAPG,,case rate,100% FL Medicaid EAPG,196.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,196.1,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,201.98,103,EAPG,,case rate,103% FL Medicaid EAPG,196.1,201.98,
MONTHLY CARE AND CASE MANAGEMENT SERVICES,2070,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,37.32,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,37.32,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,37.32,100,EAPG,,case rate,100% FL Medicaid EAPG,37.32,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,37.32,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,38.44,103,EAPG,,case rate,103% FL Medicaid EAPG,37.32,38.44,
MONTHLY BEHAVIORAL HEALTH CARE AND CASE MANAGEMENT SERVICES,2071,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,52.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,52.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,52.42,100,EAPG,,case rate,100% FL Medicaid EAPG,52.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,52.42,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,53.99,103,EAPG,,case rate,103% FL Medicaid EAPG,52.42,53.99,
MONTHLY TREATMENT MANAGEMENT SERVICES,2072,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,26.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,26.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,26.09,100,EAPG,,case rate,100% FL Medicaid EAPG,26.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,26.09,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,26.87,103,EAPG,,case rate,103% FL Medicaid EAPG,26.09,26.87,
BONE CONDUCTION HEARING DEVICE IMPLANTATION,3011,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5640.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5640.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5640.01,100,EAPG,,case rate,100% FL Medicaid EAPG,5640.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5640.01,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5809.21,103,EAPG,,case rate,103% FL Medicaid EAPG,5640.01,5809.21,
SPINAL IMPLANTATION OF DRUG INFUSION DEVICE,3030,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,7882.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7882.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7882.38,100,EAPG,,case rate,100% FL Medicaid EAPG,7882.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,7882.38,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,8118.85,103,EAPG,,case rate,103% FL Medicaid EAPG,7882.38,8118.85,
"INGUINAL, FEMORAL AND UMBILICAL HERNIA REPAIR",3033,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2350.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2350.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2350.08,100,EAPG,,case rate,100% FL Medicaid EAPG,2350.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2350.08,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2420.59,103,EAPG,,case rate,103% FL Medicaid EAPG,2350.08,2420.59,
ABDOMINAL HERNIA REPAIR,3035,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,2849.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2849.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2849.49,100,EAPG,,case rate,100% FL Medicaid EAPG,2849.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2849.49,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,2934.98,103,EAPG,,case rate,103% FL Medicaid EAPG,2849.49,2934.98,
OTHER TRANSPLANT PROCEDURES,3050,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,3294.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3294.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3294.73,100,EAPG,,case rate,100% FL Medicaid EAPG,3294.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3294.73,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,3393.57,103,EAPG,,case rate,103% FL Medicaid EAPG,3294.73,3393.57,
HEART AND/OR LUNG TRANSPLANT,3051,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,8281.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,8281.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,8281.2,100,EAPG,,case rate,100% FL Medicaid EAPG,8281.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,8281.2,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,8529.64,103,EAPG,,case rate,103% FL Medicaid EAPG,8281.2,8529.64,
KIDNEY TRANSPLANT,3052,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,4922.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4922.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4922.16,100,EAPG,,case rate,100% FL Medicaid EAPG,4922.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,4922.16,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5069.83,103,EAPG,,case rate,103% FL Medicaid EAPG,4922.16,5069.83,
VENTRICULAR ASSIST DEVICE PROCEDURES,3060,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,20245.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,20245.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,20245.85,100,EAPG,,case rate,100% FL Medicaid EAPG,20245.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,20245.85,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,20853.22,103,EAPG,,case rate,103% FL Medicaid EAPG,20245.85,20853.22,
EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO) PROCEDURES,3070,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,5107.18,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5107.18,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5107.18,100,EAPG,,case rate,100% FL Medicaid EAPG,5107.18,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5107.18,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,5260.4,103,EAPG,,case rate,103% FL Medicaid EAPG,5107.18,5260.4,
LEVEL I OPIOID TREATMENT PROGRAM SERVICES,4010,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,132.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,132.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,132.95,100,EAPG,,case rate,100% FL Medicaid EAPG,132.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,132.95,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,136.94,103,EAPG,,case rate,103% FL Medicaid EAPG,132.95,136.94,
LEVEL II OPIOID TREATMENT PROGRAM SERVICES,4011,EAPG,,,,,outpatient,,,,,,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,,,,,Other,Not Separately Reimbursable,245.43,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,245.43,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,245.43,100,EAPG,,case rate,100% FL Medicaid EAPG,245.43,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,245.43,100,EAPG,,case rate,100% FL Medicaid EAPG,,,,,Other,Not Separately Reimbursable,252.8,103,EAPG,,case rate,103% FL Medicaid EAPG,245.43,252.8,